Review of Systems

CHECKLIST:

-General-

? Weight loss or gain                 ? Fatigue                      ? Fever or chills

? Weakness                            ? Trouble sleeping

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-Skin-

? Rashes                                  ? Lumps                    ? Itching

? Dryness                                 ? Color changes            ? Hair and nail changes

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-Head-

? Headache                               ? Head injury

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-Ears-

? Decreased hearing                      ? Ringing in ears (tinnitus)        

? Earache                                ? Drainage

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-Eyes-

? Vision                                  ? Glasses or contacts  

? Pain                                    ? Redness                    ? Blurry or double vision

? Flashing lights                         ? Specks                     ? Glaucoma

? Cataracts                               ? Last eye exam

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-Nose-

? Stuffiness                              ? Discharge                 ? Itching

? Hay fever                               ? Nosebleeds                ? Sinus pain

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-Throat-

? Teeth                                   ? Gums                      ? Bleeding

? Dentures                                ? Sore tongue               ? Dry mouth

? Sore throat                             ? Hoarseness                ? Thrush

? Non-healing sores                       ? Last dental exam

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-Neck-

? Lumps                                   ? Swollen glands         

? Pain                                    ? Stiffness

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-Breasts-

? Lumps                                   ? Pain               ? Discharge

? Self-exams                              ? Breast-feeding

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-Respiratory-

? Cough (dry or wet, productive)                          ? Sputum (color and amount)

? Coughing up blood (hemoptysis)                          ? Shortness of breath (dyspnea)

? Wheezing                                                ? Painful breathing

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-Cardiovascular-

? Chest pain or discomfort                      ? Tightness                   ? Palpitations

? Shortness of breath with activity (dyspnea)                 

? Difficulty breathing lying down (orthopnea)                                 ? Swelling (edema)

? Sudden awakening from sleep with shortness of breath (Paroxysmal Nocturnal Dyspnea)

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-Gastrointestinal-

? Swallowing difficulties                         ? Heartburn                   ? Change in appetite

? Nausea                                          ? Change in bowel habits

? Rectal bleeding                                 ? Constipation                ? Diarrhea

?Yellow eyes or skin (jaundice)

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-Urinary-

? Frequency                                       ? Urgency                     ? Burning or pain

? Blood in urine (hematuria)                      ? Incontinence

? Change in urinary strengt

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-Genital- 

Male-

? Pain with sex                                  ? Hernia                        ? Penile discharge

? Sores                                          ? Masses or pain

? Erectile dysfunction                           ? STD’s 

Female-

? Pain with sex                                  ? Vaginal dryness                ? Hot flashes

? Vaginal discharge                              ? Itching or rash ? STD’s

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-Vascular-

? Calf pain with walking (Claudication)          ? Leg cramping

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-Musculoskeletal-

? Muscle or joint pain                            ? Stiffness                    ? Back pain

? Redness of joints                               ? Swelling of joints           ? Trauma

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-Neurologic-

? Dizziness                                        ? Fainting                     ? Seizures

? Weakness                                         ? Numbness                     ? Tingling

? Tremor

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-Hematologic-

? Ease of bruising                                 ? Ease of bleeding

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-Endocrine-

? Head or cold intolerance                          ? Sweating                    ? Frequent urination (polyuria)

? Thirst (polydypsia)                               ? Change in appetite (polyphagia)

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-Psychiatric-

? Nervousness                                        ? Depression                 ? Memory loss

? Stress