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Review of Systems

Review of Systems

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Published by: Carrboro Family Medicine on Apr 14, 2010
Copyright:Attribution Non-commercial

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05/12/2014

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Carrboro Family Medicine Center
 Review of Systems
Name: ______________________________Physician: ___________________ Date: _______________________________Chart#: ______________________ 
YesNoGeneral:(Comments to be completed by provider)
 ______Loss of appetite ______Fatigue ______Fever ______Change in weight ______Do you smoke? ______ if so, do you wish to quit? ______Do you drink alcohol? ______ if so, over two drinks daily? ______Follow low cholesterol diet? ______Exercise __________How many hours a week? ______Date of last Tetanus shot
 
Skin:
 ______Skin problems ______Unusual or changed moles
Head, eyes, ears, nose, throat: _________ 
Date of last dental exam __________Date of last eye exam ______Eye/Vision problems ______Nasal congestion ______Runny nose ______Hearing difficulty ______Chronic sore throat
 
Neck:
 ______Swollen glands
Respiratory:
 ______Chronic cough ______Shortness of breath ______Wheezing
Breast:
 ______Monthly self breast exam ______Breast mass ______Breast pain ______Nipple discharge ______Skin changes
Cardiovascular:
 ______Chest pain or tightness ______Edema or swollen ankles ______Palpitations ______Wake up suffocating
Please continue on the back of this form.
 
YesNoGastrointestinal:(Comments to Be Completed By Provider)
 ___________Date of last sigmoid/colonoscopy ______Abdominal pain ______Constipation ______Diarrhea ______Difficulty Swallowing ______Frequent Heartburn ______Hemorrhoids ______Blood in stool or black stool ______Nausea or vomiting
 
Female Genitourinary:
 
Male Genitourinary: Yes No
 __________Date of last menstrual periodPainful urination_____ __________Date of last bone densityPink/red urine_____ __________Date of last mammogram# urinations at night_____ __________Date of last PAPTesticular exam_____ ______History of abnormal PAPMonthly testicular exam_____ ______Pain with intercoursePenile discharge_____ ______Painful urination ______Pink/red urine ______Incontinence of urine ______Menstrual problems/irregularity __________Form of contraception ______Vaginal discharge ______Worried about sexual diseases
 
Musculoskeletal:
 ______Back or neck pain ______Joint pain ______Joint swelling ______Muscle pain
Neurological:
 ______Dizziness or fainting ______Frequent or severe headaches ______Numbness ______Weakness in extremities
 
Psychiatric:
 ______Anxiety or Nervousness ______Depression ______Insomnia or change in sleep ______Irritability
 
Endocrine:
 ______Cold intolerance ______Hair loss ______Heat intolerance ______Hot flashes ______Decreased libido ______Sexual dysfunction
Hematology:
 ______Enlarged lymph nodes
 
Current meds:Herbs or Supplements: __________________________________________________________ 
 
Seeing any Specialists (indicate name and reason):
 
 ___________________________________  _____________________________________________________________________________

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