REVIEW OF SYSTEMS
Cardiovascular: Ear/Nose/Throat: Musculoskeletal:
Present Past No Present Past No Present Past No Poor circulation Dizziness Gout High blood pressure Hearing loss Arthritis Aortic Aneurysm Sinus infection Joint stiffness Heart disease Nosebleed Muscle weakness Vascular disease Sore throat Osteoporosis Heart attack Difficulty swallowing Broken bones Chest pain Bleeding gums Joints replace High cholesterol None of the above None of the above Pacemaker Jaw pain Irregular heartbeat Eyes: Neurological: Swelling of legs Present Past No None of the above Present Past No Glaucoma Stroke Double vision Seizures Blurred vision Genitourinary: Head injury None of the above Brain aneurysm Present Past No Numbness Kidney disease Integumentary: Severe headaches Lower side pain Pinched nerves Burning urination Present Past No Parkinson's disease Frequent urination Skin ulcers Carpal tunnel Blood and urine Skin disease Standing/Balance Kidney stone Eczema None of the above None of the above Psoriasis Rashes None of the above Endocrine: Hematologic/Lymphatic: Present Past No Present Past No Allergic/Immunologic: Thyroid disease Hepatitis Diabetes Blood clots Present Past No Hair loss Cancer Hives Menopausal Easy bruising Immune disorder Menstrual problems Easy bleeding HIV/AIDS None of the above Fever/Chills/Sweats Allergy shot None of the above Cortisone use None of the above Psychiatric:
Respiratory: Present Past No Gastrointestinal: Depression Present Past No Anxiety disorder Present Past No Asthma Unusual stress Gallbladder problems Tuberculosis None of the above Bowel problems Shortness of breath Constipation Emphysema Liver problems Cold/Flu Constitutional: Ulcers Cough/Wheezing Diarrhea None of the above Present Past No Nausea/Vomiting Weight loss/gain Bloody stools Energy level problems Poor appetite Difficulty sleeping None of the above None of the above