REVIEW OF SYSTEMS

SKIN Nipple discharge Clots in veins

Rashes BSE
Itching MUSCULOSKELETAL
Change in hair or nails RESPIRATORY/CARDIAC Pain
Shortness of breath Swelling
HEAD Cough Stiffness
Headaches Production of phlegm, color Decreased joint motion
Head injury Wheezing Broken bone
Coughing up Serious sprains
EYES blood Chest pain
Arthritis
Fever
Glasses or contacts Gout
Night sweats
Change in vision Swelling in hands/feet NEUROLOGIC
Eye pain Blue fingers/toes Headaches
Double vision High blood pressure Seizures
Flashing lights Skipping heart beats Loss of
Glaucoma/Cataracts Heart murmur Consciousness/Fainting
Last eye exam HX of heart Medication Paralysis
Bronchitis/emphysema Weakness
EARS Rheumatic heart disease Loss of muscle size
Change in Muscle spasm
Hearing Ear pain GASROINTESTINAL
Tremor
Ear discharge Change of appetite or
Involuntary movement
Ringing Weight
Incoordination
Dizziness Problems swallowing
Numbness
Nausea Feeling of “pins and
NOSE/SINUSES Heartburn needles/tingles”
Nose bleeds Vomiting
Nasal stuffiness Vomiting blood HEMATOLOGIC
Frequent colds Constipation Anemia
Diarrhea Easy bruising/bleeding
ALLERGIES Change in bowel habits Past Transfusions
Hives Abdominal pain
Swelling of lips or tongue ENDOCRINE
Excessive belching
Hay fever Excessive flatus Abnormal growth
Asthma Yellow color of skin Increased appetite
Eczema/Sensitive (jaundice/hepatitis) Increased thirst
Sensitivity to drugs, food, Food intolerance Increased urine production
pollens, or dander Rectal bleeding/ Thyroid trouble
Hemorrhoids Heat/cold intolerance
MOUTH/THROAT Excessive sweating
URINARY Diabetes
Bleeding gums Difficulty in urination
Sore tongue Pain or burning on urination PSYCHIATRIC
Sore throat Frequent urination at night Tension/Anxiety
Hoarseness Urgent need to Depression/suicide ideation
urinate Incontinence Memory problems
NECK of urine Dribbling Unusual problems
Lumps Decreased urine stream Sleep problems
Swollen glands Blood in urine Past treatment with
Goiter UTI/stones/prostate Psychiatrist
Stiffness infection Change in mood/change in
attitude towards family/friends
BREAST
Lumps PERIPHERAL VASCULAR
Pain Leg cramps
Varicose veins