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 .