Review of Systems Check if you currently have or recently have had any of the following problems or concerns GENERAL CV (HEART) o Vomiting GU (URINARY MALE) o Fever o Difficulty breathing o Yellowish skin color o Dysuria o Chills o Near fainting o Gas o Hematuria o Sweats o Chest pain of o Abdominal pain o Discharge discomfort o Anorexia o Racing/skipping o Abdominal bloating o Urinary frequency heart beats o Fatigue o Fatigue o Hemorrhoids o Urinary urgency o Weakness o Lightheadedness o Diarrhea o Blood in urine o Malaise o Shortness of breath o Change in bowel o Inability to empty with exertion habits bladder o Weight Loss o Palpitations o Constipation o Kidney pain o Sleep Disorder o Swelling of o Dark tarry stools o Trouble starting hands/feet urinary stream EYES o Difficulty breathing o Bloody stools o Painful urination while laying down o Vision loss-1 eye o Fainting GU (URINARY FEMALE) ○ Inability to control bladder o Double Vision o Leg cramps with o Foul urinary o Unusual urinary exertion discharge color o Eye irritation o Blush discoloration o Blood in urine o Nocturia of lips or nails o Vision loss-both eyes o Weight gain o Urinary frequency o Incontinence o Blurring RESP (LUNGS) o Inability to empty o Genital sores bladder o Eye pain o Sleep disturbance o Urinary urgency o Decreased libido due to breathing o Halos o Cough o Kidney pain o Erectile dysfunction o Discharge o Shortness of breath o Trouble starting MUSCLES AND JOINTS urinary stream o Light sensitivity o Coughing up blood o Painful urination ○ Muscle cramps ENT o Chest discomfort o Night time urination o Joint pain o Ringing in ears o Wheezing o Inability to control o Joint swelling bladder o Ear discharge o Excessive sputum o Genital sores o Presence of joint fluid o Earache o Excessive snoring o Lack of sexual drive ○ Back pain o Decreased hearing GI o Excessive heavy o Stiffness periods o Nasal congestion o Excessive appetite o Missed periods o Muscle weakness o Nosebleeds o Loss of appetite o Unusual urinary o Arthritis color o Difficulty swallowing o Indigestion o Other abnormal o Gout vaginal bleeding o Hoarseness o Vomiting blood o Pelvic pain o Loss of strength o Sore throat o Nausea o Muscles aches

Continued Review of Systems SKIN o Memory loss o Excessive PSYCHIATRY perspiration o Night sweats ○ Sense of great danger o Suspicious lesions o Anxiety o Change in nail beds o Thoughts of suicide o Dryness o Mental problems ○ Poor wound healing o Depression o Unusual hair o Thoughts of violence distribution o Skin cancer o Frightening visions or sound o Itching ENDOCRINOLOGY o Changes in color of o Excessive hunger skin o Flushing o Cold intolerance o Rash o Heat intolerance NEUROLOGY ○ Excessive urination o Difficulty with o Excessive thirst concentration o Poor balance ○ Weight change o Headaches HEMATOLOGY o Disturbances in o Enlarge lymph nodes coordination o Numbness o Bleeding o Inability to speak o Skin discoloration o Falling down ○ Abnormal bruising o Tingling ○ Fevers o Brief paralysis ALLERGY o Visual disturbances ○ Persistent infections ○ Seizures ○ Hives or rash o Weakness ○ Seasonal allergies o Sensation of room ○ HIV exposure spinning o Tremors o Fainting o Excessive daytime sleeping