Download please mark all the symptoms that

Date_________ Name____________________________DOB_____________
Review of Systems
New patient?--please mark all the symptoms that pertain to you currently and in the past.
Repeat visit?—mark only the symptoms that you have experienced since your last visit.
Mark all that apply-if no symptoms, mark none
GENERAL
(CONSTITUTION)
appetite loss
chills
sweats (diaphoresis)
fever
general weakness
fatigue/always tired
888(malaise)
night sweats
weight gain
weight loss
NONE of the above
EARS/NOSE/THROAT
(HENT)
congestion
ear discharge
ear pain
headaches
hearing loss
hoarseness
nosebleeds
painful swallowing
888(odynophagia)
sore throat
wheezing (stridor)
ringing in ears
888(tinnitus)
NONE of the above
EYES
blurred vision
discharge
double vision
pain
sensitivity to light
888(photophobia)
redness
vision loss-left eye
vision loss-right eye
visual disturbances
visual halos
NONE of the above
CARDIOVASCULAR
RESPIRATORY
cough
coughing up blood
888(hemoptysis)
shortness of breath
sleep disturbed due
888to breathing
snoring
sputum production
wheezing
NONE of the above
changes in nail beds
discoloration
dryness
flushing
itching
poor wound healing
rash
skin cancer
suspicious lesions
unusual hair
888distribution
NONE of the above
ENDOCRINE
MUSCULOSKELETAL
chest pain
intolerance of cold
pain in legs
intolerance of heat
111(claudication)88
excessive thirst
888a(polydipsia)
blueness around
excessive hunger
mouth or nailbeds (cyanosis) 88a8(polyphagia)
shortness of breath
excessive urination
888with exertion (dyspnea)
ggg(polyuria)
irregular heartbeats
leg swelling
near fainting
NONE of the above
aaaa(syncope)
difficulty breathing
888while lying down
HEME/LYMPH
palpitations
difficulty breathing
aaaat night (PND)
fainting (syncope)
swelling of the lymph
gggnodes (adenopathy)
bleeding
easy bruise/bleed
8aa8(orthopnea)
NONE of the above
SKIN
NONE of the above
arthritis
back pain
falls
gout
joint pain
joint swelling
muscle cramps
muscle weakness
muscle pain
888(myalgias)
neck pain
stiffness
NONE of the above
Review of Systems (continued)
New patient?--please mark all the symptoms that pertain to you currently and in the past.
Repeat visit?—mark only the symptoms that you have experienced since your last visit.
Mark all that apply-if no symptoms, mark none
GASTROINTESTINAL
GENITOURINARY
abdominal bloating
abdominal pain
appetite loss (anorexia)
change in bowel
888habits
bowel incontinence
constipation
diarrhea
difficulty swallowing
888 (dysphagia)
excessive appetite
gas (flatus)
heartburn/indigestion
vomiting blood 888
888 (hematemesis)
blood in stools 888
888 (hematochezia)
hemorrhoids
yellow skin color 888
888 (jaundice)
dark tarry stools 888
888 (melena)
nausea
vomiting
bladder incontinence
decreased sex drive
888 (libido)
painful or difficult
aaaurination (dysuria)
flank pain
frequency
genital sores
blood in urine (hematuria)
trouble starting urinary
888stream (hesitancy)
incomplete emptying
888of bladder
excessive heavy
888periods (menorrhagia)
missed periods 888
888 (menses)
excessive urination at
888night (nocturia)
non-menstrual
888bleeding
pelvic pain
excessive urination 888
888 (polyuria)
urgency
NONE of the above
NONE of the above
8.11.11
NEUROLOGIC
PSYCHIATRIC
trouble with
altered mental
888speech (aphonia)
888status
brief paralysis
depression
concentration
hallucinations
888difficulty
difficulty sleeping
coordination
888 (insomnia)
888disturbed
memory loss
daytime sleepiness
nervous/anxious
dizziness
substance abuse
local weakness
suicidal ideas
light-headedness
thoughts of
loss of balance
888violence
numbness
NONE of the above
numbing or
111(paresthesias)
ALLERGY/IMMUNE
seizures
loss of feeling 888
gggg(sensory change)
tremor
sensation of room
888spinning (vertigo)
environmental
888allergies
HIV exposure
hives
persistent infection
NONE of the above
None of the above