Review of Systems
Respond to each item using the following legend:
C= Currently F= Frequently O= Occasionally S= Seldom P= Past N= Never
___
___
___
___
___
___
___
___
___
___
___
___
___
Skin
Rashes
Eczema
Psoriasis
Hives
Acne
Itching
Night sweats
Dryness
Change in moles
Change in colour/texture
Loss in hair
Skin Cancer
Warts
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
Eyes
Near-sighted
Far-sighted
Night/colour blindness
Eye pain
Glasses/Contacts
Double Vision
Blind Spot
Cataracts
Glaucoma
Blurry Vision
Dry eyes
Itchy eyes
Tearing
Red eyes
Discharge
___
___
___
___
___
___
___
___
___
Mouth/Throat
Frequent sore throat
Sore tongue/mouth
Gum problems
Grinding of teeth
Hoarseness
Dental fillings #___
Loss of taste
Trouble swallowing
Cold sores
___
___
___
___
___
___
Head
Headaches
Migraines
Dizziness
Trauma to head
Excessive hair loss
Dandruff
___
___
___
___
___
___
___
___
Ears
Ringing
Impaired hearing
Earache/infections
Dizziness
Discharge
Wax build up
Itchy
Tubes
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
Upper Respiratory
Frequent colds
Wheezing
Tonsillitis
Swollen neck glands
Sinus problems/infections
Nasal discharge
Post nasal drip
Seasonal allergies
Nose bleeds
Coughing
Sputum
Hoarseness
Wheezing
Asthma
Spitting up blood
Shortness of breath
“
while lying down
Pain on breathing
Difficulty breathing
Bronchitis
Pneumonia
Tuberculosis
Chest x-rays
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
Gastrointestinal
Indigestion
Decrease in appetite
Increase in appetite
Increase in thirst
Food Allergies
Heart Burn
Nausea
Vomiting
Excessive belching
Excessive passing gas
Bloating
Jaundice (yellow skin)
Liver Disease
Gall Bladder disease/stones
Hernia
Ulcer
Irritable bowel syndrome
Crohn’s disease
Colitis
Loose stools
Hard stools
Mucous in stool
Blood in stool
Black tarry stool
Yellow/pale stool
Greenish stool
Rectal bleeding
Hemorrhoids
Rectal fissures
Diverticulitis
Abdominal pain
___
___
___
___
___
___
___
Blood/Lymph
Anemia (low iron in blood)
Easy bruising
Easy bleeding
Past transfusions
Lymph node swelling
Blood disease
Blood Type: _____
___
___
___
___
___
___
___
___
___
___
___
Cardiovascular
Rapid heart beat
Heart Disease
Angina
High blood pressure
High cholesterol
Heart murmurs
Rheumatic fever
Chest pains
Palpitation/fluttering
Swelling in ankles
Abnormal heart tests
___
___
___
___
___
___
Peripheral Vascular
Extremity swelling
Varicose veins
Extremity numbness
Deep leg pain
Extremity coldness
Extremity ulcers
___
___
___
___
___
___
___
___
Neurological
Fainting
Seizures/convulsions
Tingling/numbness
Involuntary movement
Loss of balance
Speech problems
Loss of memory
Paralysis
___
___
___
___
___
___
___
___
___
Endocrine/Hormonal
Thyroid problems
Heat/cold intolerance
Excess sweating
Hypoglycemia
Chronic fatigue
Hormone therapy
Diabetes
Seasonal depression
Shift Work
___
___
___
___
___
Breasts
Lumps
Pain or tenderness
Nipple discharge
Breast implants
Regular self exam
___
___
___
___
___
___
___
___
___
___
___
___
Musculoskeletal
Joint pain
Joint stiffness
Joint swelling
Osteoarthritis
Rheumatoid arthritis
Muscle cramps/spasms
Backache
Neck pain/stiffness
Flat feet/pain
Weakness
Sprain joints easily
Broken bones
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
Emotional
Angry
Anxiety
Argumentative
Bad temper
Depression
Fear
Grief
Insomnia
Irritable
Low patience
Low self image
Mood swings
Nervousness/breakdowns
Panic attacks
Pessimism
Phobias
Suicidal tendency
Worrier
___
___
___
___
___
___
___
___
___
___
___
___
___
Urinary
Frequent infections
pain on urination
Burning on urination
Increased frequency
Urination at night # ____
Increase urgency
Incontinence/dribbling
Hesitancy
Strong urine odour
Cloudy urine
Blood in urine
Bed wetting
Kidney stones
___
___
___
___
___
___
___
___
___
___
___
___
Males
Prostate problems
Prostate surgery
Hernia
Testicular masses
Testicular pain
Discharge or sores
Venereal disease
Genital Warts
Sexually active
Impotence
Premature ejaculation
Other sexual difficulties:
____________________
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
Women
Hysterectomy
Birth control pills
Irregular cycles
Bleeding between periods
Painful menses/cramps
Excessive flow
Clots with flow
Fibroids
Ovarian cysts
Cervical dysphasia
Cervical/uterine cancer
Vaginal discharge
Vaginal itching
Vaginal dryness
Hot flashes
Night sweats
Difficultly conceiving
Miscarriage(s) _____
Abortion(s) _____
Birth(s) _____
Regular PAP smears
Pain on intercourse
Venereal disease
Genital warts
Sexually active
Sexual difficulties:
________________
___
___
___
Other
___________________
___________________
___________________
Harmony Health Clinic
11 FIRST ST. ORANGEVILLE, ON, L9W 2C6 (P) 519.940.3600 (F) 519.940.0976 wellness@harmonyhealthclinic.ca