Review of Systems
Please indicate any personal history below:
□ Constitutional Symptoms
Recent weight change
Fever
Fatigue
Headaches
no
no
no
no
□ Genitourinary
yes
yes
yes
yes
□ Eyes
Eye disease or injury
Wear glasses/contact lenses
Blurred or double vision
no
no
no
yes
yes
yes
□ Ears/Nose/Mouth/Throat
Hearing loss or ringing
no yes
Earaches or drainage
no yes
Chronic sinus problems/rhinitis no yes
Nose bleeds
no yes
Mouth Sores
no yes
Bleeding gums
no yes
Bad breath or bad taste
no yes
Sore throat or voice change
no yes
Swollen glands in neck
no yes
□ Cardiovascular
Heart trouble
Chest Pain or angina pectoris
Palpitation
Swelling of feet, ankles/hands
no
no
no
no
yes
yes
yes
yes
no
yes
no
no
no
yes
yes
yes
□ Respiratory
Persistent cough/throat
Clearing not associated with
a known illness
(lasting more than 3 weeks)
Spitting up blood
Shortness of breath
Wheezing
□ Gastrointestinal
Loss of appetite
no
Change in bowel movement
no
Nausea or vomiting
no
Frequent diarrhea
no
Rectal bleeding/blood in stool no
Abdominal pain
yes
yes
yes
yes
yes
Frequent Urination
Burning or painful urination
Blood in urine
Change in force of strain
when urinating
Incontinence or dribbling
Kidney stones
□ Psychiatric
no
no
no
no
yes
yes
yes
yes
no
no
yes
yes
Sexual difficulty
no yes
Male-testicle pain
no yes
Female – pain with periods
no yes
Female – vaginal discharge
no yes
Female – irregular periods
no yes
Female - # of pregnancies
no yes
Female - # of miscarriages
no yes
Female – date of last pap smear no yes
□ Musculoskeletal
Joint pain
Joint stiffness
Weakness of muscles or joints
Muscle pain or cramps
Back pain
Difficulty in walking
no
no
no
no
no
no
yes
yes
yes
yes
yes
yes
□ Integumentary
Rash or itching
Change in skin color
Change in hair or nails
Varicose veins
Breast pain
Breast lump
Breast discharge
no yes
no yes
no yes
no yes
no yes
no yes
no yes
Memory loss or confusion
Nervousness
Depression
Insomnia
Suicidal thoughts
Violent or unusual thoughts
no
no
no
no
no
no
yes
yes
yes
yes
yes
yes
□ Endocrine
Excessive thirst or urination
Heat or cold intolerance
Skin becoming drier
Change in hat or glove size
no yes
no yes
no yes
no yes
□ Hematologic/Lymphatic
Slow to heal after cuts
no
Bleeding or bruising tendency no
Anemia
no
Phlebitis
no
Past transfusion
no
Enlarged glands
no
yes
yes
yes
yes
yes
yes
□ Allergic/Immunologic
History of skin reaction or other
Penicillin or other antibiotics no yes
Morphine, Demorol
no yes
or other narcotics
Novocain or other anesthetics no yes
Aspirin or other pain remedies no yes
Tetanus antitoxin or
no yes
other serums
Iodine Methiolate
no yes
other antiseptic
Other drugs/medications ______________
__________________________
□ Neurological
Frequent/recurring headaches
Light headed or dizzy
Convulsions or seizures
Numbness/tingling sensations
Tremors
Paralysis
no
no
no
no
no
no
yes
yes
yes
yes
yes
yes
Known food allergies ________________
___________________________________
Environmental allergies ______________
___________________________________
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be
dangerous to my health. It is my responsibility to inform the doctor’s office of any changes in my medical status. I also authorize the healthcare
staff to perform the necessary services I may need.
____________________________________________________
Patient Name
____________________________________________________
Signature of Patient/Parent/Guardian
________________
Date
Doctor’s Review
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
____________________________________________________
Doctor’s Signature
_________________
Date
HEALTH HISTORY