Download Review of Systems - Mountain Valleys Health Centers

MOUNTAIN VALLEYS HEALTH CENTERS REVIEW OF SYSTEMS
Name:___________________________ Date of Birth:_____________Today’s Date:_____________
1.
Constitutional
□ weight gain
8. Women Genitourinary/ Breast
□ weight loss
□ painful or frequent urination
□ inadequate sleep
□ blood in urine (hematuria)
□ unusual fever
□ inability to control urination
□ fatigue
(incontinence)
2. Ophthalmologic
□ pelvic pain, pain with intercourse
□ eye pain
(dyspareunia)
□ redness
□ unusual vaginal bleeding or discharge
□ dryness
□ breast lumps
□ drainage
□ unusual nipple discharge
3. Ear/Nose/Throat
9. Men Genitourinary
□ ear pain (otalgia)
□ bulge in groin
□ ringing ears (tinnitus)
□ decreased urine stream
□ decreased hearing
□ dribbling, or getting up to urinate at
□ nasal discharge
night (nocturia)
□ hoarseness
□ impaired erections
□ trouble swallowing (dysphagia)
□ blood in urine (hematuria)
□ dizziness (vertigo)
10. Neurologic
4. Cardiovascular
□ headache
□ chest pain
□ weakness on one side
□ ankle swelling (edema)
□ numbness involving face/arms/legs
□ irregular heart beat (palpitations)
□ slurred speech
□ calf pain while walking (claudication)
□ blackout spells (syncope)
□ inability to lie flat in bed at night
□ sensation of a curtain being pulled over
(orthopnea)
one eye (amaurosis fugax)
□ waking suddenly at night to catch your
□ double vision (diplopia)
breath
□ difficultly with balance (ataxia)
(paroxysmal nocturnal dyspnea-PND)
□ memory loss or lapse
5. Respiratory
11. Hematologic/ Lymphatic
□ chronic cough
□ lumps in neck/armpits/groin
□ coughing up blood (hemoptysis)
□ unusual bleeding or bruising
□ shortness of breath
12. Psychiatric
□ wheezing
□ hearing voices
6. Gastrointestinal
□ seeing things that are really not there
□ nausea
□ feeling nervous or “jittery” (anxious)
□ vomiting
□ feeling sad or worthless (depressed)
□ diarrhea
13. Musculoskeletal
□ constipation
□ back pain
□ abdominal bloating
□ neck pain
□ heartburn
□ joint pain
□ blood in stools (hematochezia)
□ joint swelling
7. Skin
□ muscle weakness
□ rash
□ pain
□ unusual “moles”
Tuberculosis (TB) Risk Assessment Questionnaire
Have you experienced any of the following symptoms:
Yes
No
1. A productive, prolonged cough
2. Coughing up blood
3. An unexplained, persistent fever
4. Unexplained, excessive fatigue
5. Unexplained weight loss
6. Have you had a tuberculin skin test within the last 6 to 12 months
- If your test was positive, were you treated
7. Have you ever traveled outside the United States? If so, where?______________________