Review of Systems
Patient Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Constitutional Symptoms
None of these
Fever
Chills
Weight Loss
Fatigue
Sweats
Other
Eyes
No problems with eyes
Change in vision
Red Eyes
Pain in Eyes
Double Vision
Dry Eyes
Blood in eye
Itchy eyes
Other
Ears Nose Mouth Throat
None of these problems
Decreased hearing
Pain in ears
Discharge from ears
Earlobe problems
Sinus pain
Sore throat
Difficulty swallowing
Pain in mouth
Lump on throat
Lump in mouth
Sores in mouth
Bleeding gums
Dental problems
Other
Cardiovascular
No heart or cardiovascular problems
Chest pain
Skipped heatbeats
Palpatations
Pain in jaw
Pain in neck
Other
Respiratory
No problems in this category
Wheezing
Pain with deep breath
Cough - dry
Cough up phlegm
Shortness of breath
Other
Gastrointestinal
No problems in this category
Pain on swallowing
Food has problem going down or sticks in chest
Frequent belching
Frequent colon gas
Heartburn
Pain in stomach
Pain in rectal area
Vomiting
Vomiting blood
Nausea
Abdominal pain
Change in bowel movements
Passed blood rectally
Other
Genital / Urinary for Men
No problems in this category
Pain in genitals
Mass or lump in genital area
Problem with getting or maintaining an erection
Pain with sex
Unable to pass urine easily
Incontinent of urine
Pain with urination
Other
Genital / Urinary for women
No problems in this category
Pain in pelvic area
Heavy periods
Painful periods
No periods
Vaginal discharge or yeast
Pain with sex
Unable to pass urine easily
Incontinent of urine
Pain with urination
Other
Musculoskeletal
No problems in this category
Pain in neck
Pain in arms
Pain in legs or feet
Pain in joints
Arthritis
Callouses on feet
Other
Skin / Breast
No problems in this category
Rash
Itching
Red skin
Change in mole
Foot Ulcer
Foot Callous
Breast lump
Unexpected Milk Production
Pain in breast
Other
Neurological
No problems in this category
Stroke
Unable to move arm
Unable to move leg
Difficulty speaking
Unable to balance
Unable to walk
Unable to smile or move facial muscles
Dizziness
Pain in feet
Numbness in feet or hands
Other
Mental Health
No problems in this category
Blue mood
Depression
Feeling of helplessness
Difficulty sleeping
Loss of interest in activities
Suicidal thoughts
Anxiety
Seeing or hearing things that aren't there
Other
Endocrine
No problems in this category
Frequent urination
Thirst
Hunger
Lump on neck
Enlarged thyroid
Dark skin
Other
Blood / Lymphatic
No problems in this category
Enlarged lymph nodes
Easy bruising
Enlarged spleen
Easy bleeding
Other
Allergy Immunology
No problems in this category
Allergies to weeds / dusts
Food allergies
Lupus
Easy to catch infections
Celiac disease
Other
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