ADULT REVIEW OF SYSTEMS USF Med Peds Clinic Circle all that apply toyou today Date Fever or Chills Weight Change Rash Fatigue Skin ulcers Itching skin Change in vision Dry Skin Eye Pain Breast pain or lump Eye Itching Eye Discharge Headaches Previous Stroke or TIA Sinus drainage Dizziness Hearing loss Previous seizure Ear/Jaw Pain Weakness Ringing in ears Numbness Sore throat Memory loss Nasal congestion Nose Bleeds Depression Mouth Sores Insomnia Hoarseness Nervousness Hallucinations Previous heart attack Previous suicide attempt Chest pain High blood pressure Increased thirst Palpitations Increased hunger Heart murmur Intolerance to heat or cold Inegular heart beat Leg swelling Swollen glands Fainting Bruising Easy Bleeding Short of Breath Anemia Asthma/Wheezing Previous Blood clot Cough Spitting up Blood Any Drug Allergies Snoring Environmental Allergies Recurrent Infections Abdominal Pain Nausea FEMALE PATIENTS ONLY: Vomiting Date of last menstrual period Constipation Abnormal vaginal bleeding Diarrhea Vaginal discharge Blood in the stool Previous abnormal pap smear Heartburn Sexual difficulties Difficulty Swallowing Black stools MALE PATIENTS ONLY: Pain or lump on testicle Painful urination Discharge from penis Urinating too often Prostate problems Getting up at night to urinate Erectile Dysfunction Blood in urine Leaking urine Do you need refills? Past urine infections Difficulty urinating

Joint pain or stiffrtess Muscle pain Previous bone or joint injury...... Previous orthopedic surgery...... Swelling in arm or leg Muscle spasms or cramps

Updated 08nll09