Review of Systems
Introduction
1. "In this next part, I'm going to ask you a series of
questions about your health. It might seem like a
lot, but the questions are important and I want to
make sure I'm being thorough" (or some
variation)
General
1. What's your usual weight?
◦ Any recent weight changes?
◦ Any clothes that fit more tightly or loosely than
before?
2. Any weakness, fatigue, or fever?
3. Any hay fever?
4. Any nosebleeds?
Throat (mouth, pharynx)
1. How are your teeth and gums?
2. Any bleeding gums?
3. Do you use dentures (if so, how do they fit)
4. When was your last dental examination?
5. Has your tongue been sore?
6. Any problems with dry mouth?
7. Have you had frequent sore throats or
hoarseness?
Neck
1. Any swollen glands?
2. Have you ever had a goiter?
3. Any lumps, pain, or stiffness in the neck?
Skin
1. Any rashes, lumps or sores?
2. Any itching, dryness, or changes in skin color?
3. Any changes in hair or nails?
4. Any changes in size or color of moles?
Breasts
1. Any lumps, pain, or discomfort?
2. Any nipple discharge?
3. Do you practice the breast self-examination? How
often?
HEENT
Head
1. Any headache, dizziness, or lightheadedness?
2. Any recent head injury?
Eyes
1. Any changes or problems in your vision?
2. Do you use glasses or contact lenses?
When was your last eye exam?
3. Any pain, redness, or excessive tearing?
4. Any double or blurred vision?
5. Any spots, specks, or flashing lights?
6. Have you ever been told you have glaucoma or
cataracts?
Ears
1. Any problems or changes in your hearing?
2. Any ringing (tinnitus) or vertigo?
3. Any earaches, infections, or discharge?
Nose
1. Any frequent colds or sinus trouble?
2. Any nasal stuffiness, discharge, or itching?
Respiratory
1. Any coughing? Anything coming up in the cough
(sputum: color, quantity). Any blood in your
cough (hemoptysis)?
2. Any shortness of breath (dypsnea), or wheezing?
(also pleurisy)
3. When was your last chest X-ray?
4. Optional: Any history of lung disease (asthma,
bronchitis, emphysema, pneumonia, or
tuberculosis?)
Cardiovascular
1. Any heart trouble?
2. Ever been told you have high blood pressure or
heart murmurs?
3. Any history of rheumatic fever?
4. Any chest pain or discomfort?
5. Any palpations, shortness of breath (dyspnea)
6. Any trouble breathing when you're laying down
(orthopnea), or sleeping (paroxysmal nocturnal
dyspnea)?
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Review of Systems
7. Any swelling (edema)?
8. Have you ever had an electrocardiogram (EKG) or
another cardiovascular test? What was it / when
was it / what were the results?
Gastrointestinal
Appetite & eating
1. Any trouble swallowing, heartburn, or nausea?
2. Any changes in your appetite?
3. Any problems with food intolerance?
Bowel movements
1. Any changes in your bowel habits or pain when
defecating?
2. How have your bowel movements been? How
would you describe your stool color and size
recently?
3. Any blood in your stool, or black or tarry stools?
4. Any hemorrhoids?
5. Any constipation or diarrhea?
Other
1. Any abdominal pain?
2. Any excessive belching, or passing of gas?
3. Have you noticed any yellowing of your skin
(jaundice).
4. Ever been told you have liver or gallbladder
trouble or hepatitis?
Urinary
1. Any changes or problems with how often you
have to urinate?
2. Are you urinating more than normal (polyuria) or
at night (nocturia)?
3. Any problems with urgency, incontinence,
burning, or pain when urinating?
4. Any blood in your urine (hematuria)?
5. Any urinary infections?
6. Any pain in your kidneys or flanks?
7. Any history of kidney stones?
8. Any pain above your genitals (suprapubic) or in
that area (sharp pain could be uretral colic)
9. Males: any change in the force or width of your
urinary stream? Any hesitancy or dribbling?
Genital
Male
1. Any hernias?
2. Any discharge from or sores on the penis?
3. Any testicular pain or lumps/masses?
4. Any pain or swelling in your scrotum?
5. Have you ever had a sexually transmitted disease
(history & Tx)
6. Are you sexually active? With whom? (sexual
habits, interest, function, satisfaction, birth
control, condom use, problems)
7. Have you ever been or think you might have been
exposed to HIV? Via drug use, sexual contact, or
another way?
Female
Menstruation:
1. When did you have your first period (age at
menarche)
2. How often does your period come? Is it regular?
How long do they last?
3. Would you describe your period as especially
heavy or light?
4. Any bleeding between your periods or after
intercourse?
5. When was your last period?
6. Any pain during your period (dysmenorrhea)?
7. Any changes in mood or how you feel before your
period?
8. If applicable: when did you begin menopause?
Have you had any symptoms during menopause?
Have you had any bleeding since menopause?
Other Gyn:
1. Any vaginal discharge?
2. Any itching, sores, or lumps?
3. Have you ever had a sexually transmitted disease
(history & Tx)
OB:
1. Have you ever been pregnant? How many times?
1. How many children have you delivered?
2. Any miscarriages or abortions?
3. Any complications during pregnancy?
2. Do you use birth control? What kind?
3. Are you sexually active? With whom? (interest,
function, satisfaction, any problems?). Any
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Review of Systems
pain during intercourse (dyspreunia)?
4. Have you ever been or think you might have been
exposed to HIV? Via drug use, sexual contact,
or another way?
5. If patient born before 1971: Any exposure to
diethylsilbestrol (DES) from maternal use during
pregnancy?
Peripheral Vascular:
1. Any muscle pain (intermittent claudication), or leg
cramps?
2. Any varicose veins?
3. Have you ever had clots in your veins?
4. Any swelling in your calves, legs, or feet?
5. Any changes in the color of your fingertips or toes
during cold weather?
6. Any swelling with redness or tenderness?
Musculoskeletal
1. Any muscle or joint pain?
2. Any stiffness, arthritis, or gout?
3. Any back pain?
4. Any pain in your neck or lower back?
5. Any joint pain with fever, chills, rash, loss of
appetite (anorexia), weight loss, or weakness?
6. If present,
1. Describe location of affected joints/muscles,
swelling, rendess, pain, tenderness, stiffness,
weakness, limitations of motions or activity
2. Give PQRST & history of trauma if applicable
4. Any headache, dizziness, or vertigo?
5. Any fainting, blackouts, or seizures?
6. Any weakness, paralysis, numbness or loss of
sensation?
7. Any feelings of tingling or "pins and needles"?
8. Any tremors or other involuntary movements?
9. Have you ever had a seizure?
Hematologic
1. Any history of anemia?
2. Do you bruise or bleed easily?
3. Have you ever had any transfusion (if yes,
reactions to transfusions)
Endocrine
1. Have you ever had thyroid trouble? Any
intolerance to heat or cold?
2. Any excessive sweating, thirst, or hunger
3. Any excessive urination?
4. Any changes in glove or shoe size?
Psychiatric
1. Have you been feeling nervous or tense recently?
2. How's your mood been?
3. Have you had any problems with your memory?
4. Have you been feeling depressed / suicide
attempts (if relevant)
Neurologic
1. Any changes in mood, attention, or speech?
2. Any changes in memory, judgment, or insight?
3. Have you ever become disoriented, lost track of
where you were, or what time it was?
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