Date of visit: __________
Review of Systems
Patient name: ___________________ Date of birth: __________
Are you currently experiencing any of these conditions? Please check all that apply.
Constitutional:
Cardiovascular:
Metabolic/Endocrine:
Integumentary:
__ Fatigue
__ Fever
__ Night sweats
__ Weakness
__ Weight gain
__ Weight loss
__ Other __________
__ Arrhythmia
__ Calf pain
__ Chest pressure or discomfort
__ Irregular heartbeat/palpitations
__ Leg swelling
__ Tachycardia
__ Other __________
__ Cold intolerance
__ Heat intolerance
__ Polydipsia
__ Polyphagia
__ Polyuria
__ Other __________
HEENT:
Gastrointestinal:
__ Exophthalmos
__ Hearing loss
__ Hoarseness
__ Lump in neck
__ Nasal congestion
__ Sinus problems
__ Sore throat
__ Tinnitus
__ Vertigo
__ Other __________
__ Abdominal pain
__ Black tarry stools
__ Constipation
__ Decreased appetite
__ Diarrhea
__ Dysphagia
__ Food intolerance
__ Heartburn
__ Increased appetite
__ Jaundice
__ Nausea
__ Vomiting
__ Other __________
__ Abnormal hair distribution
__ Dry skin
__ Hives
__ Itching skin
__ Nail changes
__ Rash
__ Skin changes
__ Skin lesion
__ Skin nodules
__ Skin sores
__ Ulcer
__ Other __________
Neurological:
Respiratory:
__ Asthma
__ Cough
__ Dyspnea
__ Dyspnea on exertion
__ Hemoptysis
__ Wheezing
__ Other __________
Genitourinary:
__ Dysuria
__ Genital lesions
__ Hematuria
__ Irregular menses
__ Urethral discharge
__ Urgency
__ Other __________
If none of these symptoms apply check here: N/A ___
__ Balance disturbances
__ Dizziness
__ Focal weakness
__ Gait disturbance
__ Headache
__ Memory difficulty
__ Numbness of extremities
__ Other __________
Psychiatric:
__ Depressed mood
__ Emotional changes
__ Euphoria
__ Frequent nightmares
__ Hallucinations
__ Insomnia
__ Irritability
__ Nervousness
__ Stress
__ Other __________
Musculoskeletal:
__ Arthralgias
__ Back pain
__ Fracture
__ Joint stiffness
__ Joint swelling
__ Muscle cramping
__ Muscle weakness
__ Other __________
Hematologic/Lymphatic:
__ Bleeding
__ Bruising
__ Lymphadenopathy
__ Tender lymph nodes
__ Other __________
Immunologic:
__ Environmental allergies
__ Food allergies
__ Seasonal allergies
__ Other __________