Review of Systems

General/ Constitutional

Head/ Ears/ Nose/ Throat

	Yes	No
Frequent or severe headaches
Glasses or contact lenses
Impaired Hearing
Nasal discharge, drainage, or sneezing

When was your last eye exam?

Date

Neurological

	Yes	No
Memory loss
Fainting, dizziness, seizures, or convulsions

Musculoskeletal

	Yes	No
Pain in joint/ Arthritis
Chronic back pain or injury

Respiratory

Endocrine

Gastrointestinal

Hematologic/ Lymph

	Yes	No
Anemia
Excessive bleeding or abnormal bruising
Blood transfusion
Swelling of lymph nodes

Cardiovascular

	Yes	No
Rheumatic fever
Pain and/or pressure in chest
Palpitation
Abnormal heart rhythm or murmur
Swelling of ankles
High blood pressure

Urinary

	Yes	No
Frequent urination at night
Frequent or painful urination
Difficulty holding urine
Difficulty stopping and/or starting urine
Urinary tract infection

Skin/ Breast

Emotional

	Yes	No
Do you have trouble sleeping?
Are you depressed?
Are you often anxious or nervous?
Memory loss

Assigned Male at Birth

	Yes	No
Sore/ discharge from penis
Lumps and/or pain in testicule
Sexually Transmitted Infection/ Disease
Condom use
Problem with sexual function

Assigned Female at Birth

	Yes	No
Method of birth control
Mid-cycle bleeding
Pain with intercourse
Vaginal discharge or sores
Painful periods
Sexually Transmitted Infection/ Disease
Problems with sexual function
Regular menstrual cycle
Have you ever been pregnant?

Optional

	Yes	No
Are you sexually active?
Opposite sex
Same sex
Both
If sexually active with the opposite sex, do you use contraception?

If you use contraception, what kind?

Please explain any condition that was checked yes:

Name*

First NameLast Name

Date of Birth*

Date

Today's date*

Date