Download Patient Review of Systems Date

Patient Review of Systems
Name: _____________________
Date: _________________
DOB: _____________
Have you recently been bothered by any of the following? Check the box in front of
the symptom or circle it.
General:
□ fever □chills □ sweats □ loss of appetite □ fatigue □ weakness □ tiredness
□ weight loss □ sleep disturbance
Eyes:
□ vision loss □ seeing double □ irritation □ blurry vision □ eye pain □ seeing
halos □ discharge □ light sensitivity
Ears/Nose/Throat:
□ ringing □ discharge □ earache □ decreased hearing □ nasal congestion
□ nosebleeds □ difficulty swallowing □ hoarseness □ sore throat
Cardiovascular:
□ chest pain or discomfort □ racing/skipping heart beats □ fatigue □ lightheadedness □ dizziness (spinning) □ shortness of breath with exertion □
palpitations □ swelling of hands or feet □ difficulty breathing at night or while
lying down □ fainting □ leg cramps with walking □ blue discoloration of lips or
nails □ sudden weight gain
Respiratory:
□ cough □ shortness of breath □ coughing up blood □ chest discomfort □
wheezing □ excessive sputum □ excessive snoring □ fatigue after awakening
GI (stomach and intestines):
□ excessive appetite or thirst □ loss of appetite □ frequent indigestion □ vomiting
blood □ nausea □ vomiting □ yellowish skin/eyes □ excessive gas □ abdominal
pain □ abdominal bloating □ hemorrhoids □ diarrhea □ change in bowel habits
□ constipation (hard stool) □ dark tar-like stools □ bloody BM’s or stools
GU (genitor-urinary):
□ foul smelling urine □ blood in urine or tea-colored urine □ frequent urination
□ inability to empty bladder □ urgent urination □ kidney pain □ trouble starting
urine stream □ pain with urination □ frequent night-time urination □ inability to
control urination □ sores on your genitals
Women:
□ irregular periods □ heavy periods □ missed periods □ concern that you might be
pregnant □abnormal vaginal bleeding or discharge □ painful intercourse □ pelvic
pain □ history of abnormal Pap Smears
Musculoskeletal:
□ muscle cramps □ joint pain □ joint swelling □ joint fluid □ back pain
□ stiffness □ muscle weakness □ arthritis □ gout □ loss of strength □ muscle aches
Skin:
□ excessive perspiration □ night sweats □ suspicious skin lesions □ changes in
nails □ dry skin □ poor wound healing □ changes in hair □ skin cancer □ itching □
changes in skin color □ flushing □ rash
Neurological:
□ difficulty with concentration □ poor balance □ headaches □ disturbance in
coordination □ numbness □ inability to speak or speech changes □ frequent falling
□ tingling □ brief paralysis □ visual disturbance □ seizures □ weakness
□ dizziness (spinning) □ tremors □ fainting □ excessive daytime sleepiness □
memory loss □ restless legs syndrome
Psychiatric:
□ anxiety □ feelings of panic □ feeling sad or blue frequently □ feeling hopeless
□ thoughts of suicide □ sounds, voices, or sights that no one else hears or sees
Endocrine (glandular):
□ excessive hunger □ cold intolerance □ heat intolerance □ excessive urination
□ excessive thirst □ recent weight changes
Hematological (blood):
□ enlarged lymph glands □ bleeding □ abnormal bruising □ frequent fevers
□ frequent infections
Allergy:
□ frequent congestion □ frequent hives □ seasonal allergies □ severe food
allergies □ history of severe reaction to bee or wasp sting
Infectious disease:
□ transfusion before 1991 □ tattoo under questionable hygiene standards
□ history of sharing needles (for any purpose) or of high-risk sexual relations
□ recent travel to region with an unusual disease outbreak □ recent tropical travel
□ household member with TB or other infectious disease
Further details if needed: