Review of Systems: Place with (H) if you currently HAVE this and with a (P) if you
HAVE HAD in the past
General
Mouth
Bleeding Gums
Sores
Dental Issue
Bad breath
Decreased Taste
Dry Mouth
Ulcers
Blisters
Weakness
Fatigue
Fever
Chills/Night Sweat
Fainting
Skin
Color Changes
Nail/Hair Changes
Moles/Rashes
Sores
Soreness
Bad Tonsils
Hoarseness
Pain
Trouble Swallowing
Recurrent Infections
Neck
Neck Enlargement
Stiff neck
Soreness
Lumps
Masses
Ears
Hard of Hearing
Ringing
Discharge
Earache
Itching
Dizziness
Breasts
Discharge
Lumps Pain
Bleeding
Nipple Change
Skin Change
Bloated
Nose
Decreased Smell
Bleeding
Pain
Discharge
Obstruction
Post Nasal Drip
Deviated Septum
Runny Nose
Congestion
Heart
Murmur
Palpitations
Rapid heartbeat
Swollen extremities
Blue/Cold Extremities
Chest Pain/Pressure
Varicose Veins
Blood Clots
Throat
Head
Headaches
Injuries
Bumps
Last eye exam:________
Glasses/Contacts
Cataracts
Congestion
Inhalant exposure
Lungs
Cough
Phlegm
Blood
Short of Breath
Wheezing
Pain
Blood
Anemia
Low blood iron
Easy bruising/ bleeding
Swollen/Painful Nodes
Red Spots
Gastrointestinal
Abdominal Pain
Nausea
Bloating
Belching
Heartburn
Indigestion
Irregular Bowel Habits
Constipation
Diarrhea
Gas
Hemorrhoids
Poor Appetite
Food Intolerance
Black/Bloody Stools
Genitourinary
Urgency
Incontinence
Straining
Patient/Guardian Signature:______________________________________________________Date:_________________
Review of Systems: Place with (H) if you currently HAVE this and with a (P) if you
HAVE HAD in the past
Back Pain
Frequent Voiding
Stones
Burning
Bed Wetting
Small stream
Discharge
Impotence
Dribbling
Cloudy Urine
Spotting btw. Periods
Menstrual Cramps
Discharge
Itching
Painful Intercourse
Irregular Periods
Hot Flashes
Neurologic
Seizures
Vertigo
Dizziness
Hand Trembling
Loss of sensation
Incoordination
Weak grip
Paralysis
Difficult Speech
Tingling
Loss of memory
Numbness
Endocrine
Weight loss or Gain
Extremely Thing
Heat Intolerance
Cold Intolerance
Hair changes
Breast changes
Contraception:______________
Age at 1st Period:____________
Duration of Cycle:___________
Duration of flow:____________
No. of Pregnancies:__________
No. of Births:_______________
No of Miscarriages__________
No. of Abortions____________
Menstrual Flow____________
Last Period________________
Last Pap Smear____________
Last Vaginal Exam___________
Last Mammogram___________
Last Prostate Exam__________
Psychiatric
Hyperventilation
Insecurity
Depression
Trouble sleeping
Irritable
Undecidedness
Timid
Hallucinations
Loss of memory
Alcoholism
Drug addiction
Drug dependant
Suicidal
Worriedness
Sexual Issues
Musculoskeletal
Muscle Pain
Muscle Weakness
Muscle Cramps
Muscle Twitching
Joint Stiffness
Joint Pain
Past Medical History (only
select what you have HAD in
the past:
Mumps
Rheumatic Fever
Allergies
Angina
Cancer/tumor
Blood Disease
Leukemia
Heart trouble
Varicose Veins
Heart Trouble
Hypertension
Stroke
Ulcers
Jaundice
Skin Trouble
Gallstones
Hepatitis
Parasites
Epilepsy
Paralysis
Polio
Migraines
Gout
Hemorrhoids
STI’s
Kidney Stones
Bladder Trouble
Anxiety/Breakdown
Patient/Guardian Signature:______________________________________________________Date:_________________
Review of Systems: Place with (H) if you currently HAVE this and with a (P) if you
HAVE HAD in the past
Patient/Guardian Signature:______________________________________________________Date:_________________