REVIEW OF SYSTEMS **Please circle all that apply** NAME: ______
DATE: ______
ALLERGIC/ ENDOCRINE HEMATOLOGIC/ PSYCHIATRIC IMMUNOLOGIC Excessive hair growth LYMPHATIC Addiction to alcohol Drug Allergy High blood sugar Anemia Anxious feelings Environmental allergies Low blood sugar Bleeding problems Binging and purging List ______ Perimenopausal Bruise easily Claustrophobia ______symptoms Swollen lymph nodes Depression ______ Overactive thyroid Disorientation Underactive thyroid SKIN Emotional or mental CARDIOVASCULAR Tired/sluggish Acne problems abuse Cardiovascular Blisters Extreme highs and lows problems or chest EYES Burning of skin Feelings of symptoms Abrupt visual loss Groups of blisters hopelessness Chest pain Blurred vision Hair loss Libido decrease Elevated blood Double vision Skin hypersensitivity Memory loss pressure Excess tearing/watering Itchy skin Mental status change Feet swelling from eyes Rash Nightmares Heart attack Feeling of sand in eyes Tingling sensations Panic attacks Heart palpitations Light sensitivity Skin ulcerations Paranoia Fast heartbeat Pain or soreness in or Poor anger control Murmur about the eyes MUSCULOSKELETAL Poor sleep pattern Unable to breathe Progressive loss of Back pain Rape or sexual abuse easily, unless sitting vision Joint pain victim straight or standing Reddened eyes Joint swelling Suicidal thoughts upright Transient visual loss Muscle pain Suicide attempt Pacemaker Trauma to the eye Muscle tenderness Neck pain RESPIRATORY CONSTITUTIONAL GASTROINTESTINAL Asthma SYMPTOMS Bowel habit change NEUROLOGICAL Breathing difficulty Appetite change or Constipation Aura, olfactory Chest tightness decrease Heartburn Aura, visual Flu-like symptoms Fever Loss of appetite Balance problems Recent exposure to Fainting Nausea Burning tuberculosis Feeling of spinning or Vomiting Confusion Shortness of breath lightheadedness Difficulty speaking Sleep apnea (stopping Weight gain GENITOURINARY Dizziness breathing while asleep) Intentional weight loss Blood in urine Facial tic Snoring Unintentional weight Burning with urination Focal weakness Wheezing loss Currently pregnant Forgetfulness
Partner diagnosed with Headache HEIGHT:______EARS, NOSE, MOUTH, STD Hypersensitivity THROAT Excessive amounts of WEIGHT:______ Difficulty with hearing Inability to produce urine language Difficulty with Urinary frequency ADDITIONAL COMMENTS: swallowing Inability to understand Urinary incontinence language ______ Ear pain Urinary urgency Inability to read ______ Lost sense of smell Urine retention Inability to write ______ Ringing in ears Muscle weakness ______ Sinus problems Numbness ______ Sound sensitivity Paralysis ______ Seizure ______
SMOKING Sleepiness ______ No ______ Slurred speech ______ Yes ______ Tingling ______ How Much Tremors ______ ______ Uncontrolled ______movements