Review of Systems 1
REVIEW OF SYSTEMS
Place a “C” if problem is current, or a “P” if this was a problem in the past.
HEAD:
Headaches____
Migraines ____
Dizziness ____
Dandruff ____
Other ________________________________________________
EYES:
Blurry vision ____
Itchy eyes ____
Light sensitivity ____
Pain ____
Dryness ____
Redness ____
Other ________________________________________________
EARS:
Ringing ____
Infections ____
Hearing problem ____
Excess wax ____
Discharge ____
Itching ____
Other _________________________________________________
NOSE:
Sense of smell (acute, lost, etc.) ____
Sinus pain ____
DIscharge ____
Stuffiness ____
Sneezing ____
Allergies ____
Bloody noses ____
Crusts inside ____
Other _________________________________________________
MOUTH/THROAT:
Sense of taste (altered, lacking, bad taste, etc.) ____
Teeth (pain or other problems)____
Tongue ____
Bleeding gums ____
Canker sores ____
Review of Systems 2
Sore throats ____
Change in voice ____
Cold sores (Herpes) ____
Bad breath ____
Trouble swallowing ____
Lump sensation in throat ____
Other _____________________________________________________
NECK:
Thyroid issues ____
Neck pain ____
Stiffness ____
Other _____________________________________________________
CHEST:
Chest pains ____
Heart palpitations ____
Shortness of breath ____
Wheezing ____
Cough ____
Breast tenderness ____
Breast lumps ____
Other _____________________________________________________
ABDOMEN/GI:
Appetite ____
Heartburn/Reflux ____
Belching ____
Nausea ____
Stomach pain ____
Bloating/Distention ____
Abdominal pain ____
Ulcers ____
Constipation/Difficult stool ____
Diarrhea ____
Flatulence ____
Hemorrhoids ____
Change in stool (color, consistency, shape, etc.) ____
Other _____________________________________________________
GU/FEMALE:
Bladder pain/infections____
Blood in urine ____
Incontinence ____
How many times do you urinate during the night? ________________
Menstruation ____
Review of Systems 3
PMS ____
Vaginal discharge ____
History of STD’s ____
Menopause ____
Sex drive (libido) ____
Fertility issues ____
Other________________________________________________________
Age at first period: ________
Age at menopause:________
Number of pregnancies:_________
Number of miscarriages:_________
Other problems with periods: _____________________________________
GU/MALE:
Trouble urinating (starting, force of stream, incomplete emptying, etc.) ____
Incontinence ____
History of STDs____
Prostate issues ____
Testicular pain or swelling ____
Blood in urine ____
Erections ____
Sex drive (libido) ____
Other ________________________________________________________
How many times to you urinate during the night? _____
MUSCULOSKELETAL/EXTREMITIES:
Body stiffness ____
Joint pain ____
Muscle pain ____
Low back pain ____
Other back pain ____
Sciatica ____
Muscle cramps ____
Swelling/edema ____
Significant injury ____
Other _________________________________________________________
SKIN/INTEGUMENT:
Acne ____
Eczema____
Psoriasis ____
Ringworm ____
Skin cancer ____
Dry skin ____
Itchy skin ____
Easy bruising ____
Review of Systems 4
Discolorations ____
Nails (soft, slow growing, brittle, ridged, etc.) ____
Hangnails ____
Hair falling out ____
Hair went gray early ____
Ingrown toenails ____
Moles/skin tags ____
Skin infections ____
Tendency to poison ivy ____
Sensitive to metals ____
Other ____________________________________________________
NEUROLOGIC:
Fainting or feeling faint ____
Seizures ____
Tremors ____
Balance problems ____
Numbness ____
Weakness ____
Tingling ____
Other ____________________________________________________
MENTAL/EMOTIONAL:
Depression ____
Anxiety ____
Anger ____
Irritability ____
Mood changes ____
Concentration/focus ____
Memory ____
Confusion ____
Change in behavior ____
GENERAL:
Weight gain ____
Weight loss ____
Fever ____
Chills ____
Night sweats ____
Difficulty sleeping ____
Fatigue ____
Anemia ____
Reaction to vaccination ____
Other ______________________________________________________