Review of Systems
 
Your Name  
Reason for visit  
 
Please consider and mark each of the bold sections below
Be sure tocheck any and all boxes that apply
 
GENERAL
None Weight loss
Night sweats 		Anorexia
Feeling well 		Fever Other
SKIN
None
Ulcer 		Hives
Itching 		Change in wart/mole
Excessive sweating 		New lesions
Skin color change 		Pallor
Other
HEENT
None Headache
Head injury 		Wear glasses/contacts
Vision changes 		Deafness
Nose bleeds 		Voice changes
Other
NECK
None Neck mass Swollen glands   Other
RESPIRATORY
None Shortness of
breath 		Decreased exercise
tolerance 		Chronic cough
Bloody sputum 		Other
BREAST
None Breast pain
Nipple discharge 		Mass/lump
Skin changes 		Nipple pain
Rash 		Other
CARDIOVASCULAR
None
Cold feet 		Swelling of
extremities
Phlebitis 		Difficulty Breathing
while lying down
on exertion 		Difficulty walking
short distances
Leg pain 		Hypertension
Other
GASTROINTESTINAL
None
Reflux
Constipation 		Abdominal pain
Bloody stool
Diarrhea 		Change in bowel habits
Difficulty swallowing
Black/tarry stool 		Nausea/vomiting
Hemorrhoids
Indigestion 		Jaundice
Rectal bleeding
Other
GENITOURINARY
None Contraceptives Change in urinary pattern Flank pain Other
MUSCULOSKELETAL
None Leg Cramps Muscle weakness Myalgia Other
NEUROLOGICAL
None
Numbness 		Trouble waking
Tremor 		Difficulty speaking
Incontinence stool 		Weakness
Unsteadiness 		Other
PSYCHIATRIC
None Depression Anxiety   Other
ENDOCRINE
None Diabetes
Cold intolerance 		Appetite changes
Heat intolerance 		Excessive thirst
Thyroid problems 		Other
HEMATOLOIC/LYMPHATICS
None Anemia
Blood clots 		Pinpoint hemorrhages Easy bruising Other