CHECKLIST: Review of Systems

CHECKLIST: Review of Systems

<p> Dr. Kristin K. Titko</p><p>513-729-4455</p><p>CHECKLIST: Review of Systems</p><p>General- Cardiovascular- Endocrine- Weight loss Cold feet  Weight gain □Night cramps Sweating Fatigue □Intermittent claudication Frequent urination Fever or chills Swelling of feet/ankles Thirst Weakness Heart disease Change in appetite Loss of Appetite Diabetes Gastrointestinal- If yes - Type 1 or Type 2 Skin- Indigestion (Dyspepsia) Ulcers Itching (pruritis) Diarrhea Surgical Concerns- Dryness GI bleeding Anesthesia problems Open wounds □Liver disease Wound healing Nail changes/fungus problems Rashes Vascular- Calf Pain with walking Please check if you are Respiratory- Leg cramping being treated for any Shortness□ of breath of the following: COPD Psychiatric- Thyroid Painful breathing Nervousness Osteopenia Asthma Stress Drug abuse Cough Depression COPD Memory loss AIDS/HIV Musculoskeletal □ Hepatitis□ -Joint/muscleJoint/muscle stiffnessstiffness Neurologic- Alcoholism Back pain burning in feet/legs □Alzheimer’s Redness of joints Seizures Blood Clots where? Swelling of joints Unsteady gait Cancer where? Osteoarthritis Tremors High Cholesterol Gout Dizziness □Diabetes Rheumatoid Arthritis Fainting High Blood Pressure Muscle or joint pain Tingling in feet/legs CVA/Stroke Numbness in feet/legs ⎕ Kidney Disease Hematologic- Weakness in feet/legs ⎕Take Blood Thinner</p><p>Ease of bleeding Current weight?______Ease of bruising Current height?______List Other Medical Conditions:</p><p>I do not have any of the above conditions</p><p>Patient’s Name: ______Patient Signature:______Date: ______</p>

View Full Text

Details

  • File Type
    pdf
  • Upload Time
    -
  • Content Languages
    English
  • Upload User
    Anonymous/Not logged-in
  • File Pages
    2 Page
  • File Size
    -

Download

Channel Download Status
Express Download Enable

Copyright

We respect the copyrights and intellectual property rights of all users. All uploaded documents are either original works of the uploader or authorized works of the rightful owners.

  • Not to be reproduced or distributed without explicit permission.
  • Not used for commercial purposes outside of approved use cases.
  • Not used to infringe on the rights of the original creators.
  • If you believe any content infringes your copyright, please contact us immediately.

Support

For help with questions, suggestions, or problems, please contact us