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I.

REVIEW OF SYSTEMS
a) General Health Survey
Weight Loss/Gain Fever
Trouble Sleeping Chills
Weakness Fatigue
Difficulty doing ADLs Others

Pertinent Findings:

b) Skin, Hair, and Nails


Rashes Itching
Scars Ulcers
Warts Color changes
Lumps Dryness
Hair changes Others:
Nail changes

Pertinent Findings: No pertinent data noted.

c) Head and Neck


Headache Head injury
Stiff Neck Lumps
History of concussion or loss of Others
consciousness

d) Eyes
Vision Double vision
Cataracts Glasses
Flashing Lights Last eye exam
Pain Specks
Redness Itching
Tearing Eye Surgery
Strabismus Light sensitivity
Blurring of vision Others

e) Ears
Difficulty hearing Tinnitus
Vertigo Ear pain
Ear-care habits Others:

f) Nose and Sinuses


Stuffiness Itching
Nosebleeds Discharge
Sinus Infection Others
g) Mouth and Throat
Teeth Sore throat
Thrust Gums
Dry mouth Non-healing
Bleeding Sore Throat
Last Dental Exam Dentures
Hoarseness Dental Hygiene Patterns
Difficulty chewing or swallowing Others

h) Respiratory
Cough Hemoptysis
Wheezing Dyspnea
Trouble breathing during exercise PPD
Trouble breathing lying flat Others

i) Cardiovascular
Chest pain Cyanosis and coldness of extremities
Palpitations Chest tightness
Shortness of breath with activity, Murmurs
when lying down or upon Others
awakening

j) Breasts
Lumps Discharge
Breastfeeding Pain
Breast Cancer Breast Surgery
BSE Clinical Breast Exam
Last mammogram Others:

k) Gastrointestinal
Change in bowel habits Jaundice
Heartburn Rectal Bleeding
Change in appetite Constipation
Nausea Diarrhea
Hematemesis Hemorrhoids
Use of laxatives and antacids Others

l) Genitourinary
Frequency of urination Burning/ Pain in urination
Urgency Incontinence
History of UTI, kidney disease, Frequent nightmare urination
kidney stones Others
Hematuria

m) Reproductive
Menarche LMP Dysmenorrhea
Excessive Bleeding Irregular Menses Metrorrhagia
Use ofcontraceptives STDs Infertility Problems
Obstetrical History Vaginal Dryness Hot flashes
Others:

n) Neuroligical
Dizziness Fainting
Tremors Numbness
Tingling Seizures
Speech Problems Problems with gait, balance
Others: Memory problems

o) Musculoskeletal
Muscle or joint pain Back pain
Swelling of joints Stiffness
Redness of joints Trauma
Fractures Joint deformity
Spinal deformities Others: Pruritic Edema

p) Immune/Hematologic
Ease of bruising Ease of bleeding
Recurrent Infections Unexplained swollen glands
Blood transfusions Cancers
HIV Others

q) Endocrine
Heat or cold intolerance Sweating
Increased thirst, hunger Hormone Therapy
Endocrine disorders (thyroid Others
disease, goiter, DM)

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