Review of Systems
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Today's date
*
-
Month
-
Day
Year
Date
General/ Constitutional
Yes
No
Weight Loss
Weight Gain
Excessive Fatigue
Prolonged fever/ chills
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?
-
Month
-
Day
Year
Date
Neurological
Yes
No
Memory loss
Fainting, dizziness, seizures, or convulsions
Musculoskeletal
Yes
No
Pain in joint/ Arthritis
Chronic back pain or injury
Respiratory
Yes
No
Chronic cough
Asthma or wheezing
Shortness of breath
Endocrine
Yes
No
Cold or heat intolerance
Thyroid problems
Excessive thirst
Gastrointestinal
Yes
No
Abdominal pain
Loss of appetite
Change in bowel habits
Blood in stool
Hemorrhoids
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
Yes
No
Change or new growth in mole
Breast lump
Breast/ nipple discharge
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:
Submit
Should be Empty: