PHYSICAL EXAMINATION AND REVIEW OF SYSTEMS

Date: ______________

Vital Signs:
Temp: _________ RR: __________ Weight: ______________
PR: __________ BP: __________ Height: ______________

Observation: _______________________________________________________________________________________

1. General (weight loss or gain; fever,

chills, night sweats; mood; stage of
development, race, sex; signs of
distress; position; cooperative or not;
state if irritable, agitated or pleasant;
etc.)

2. Head (headache, injury,

tenderness, etc.); Eyes (change in
visual fields, glasses, blurring,
diplopia, pain, loss of vision, tearing,
dry eyes, etc.); Ears (change in
hearing, tinnitus, discharge, dizziness,
etc.); Nose (allergies, sinus problem,
obstruction, polyps, sneezing,
epistaxis, etc.);Throat (toothaches,
loose teeth, bleeding gums, mouth
sores, hoarseness, difficulty
swallowing, etc.)
3. Integumentary System

4. Respiratory System
(chest pain, dyspnea, cough, amount
and color of sputum, hemoptysis, etc.)

5.Cardiovascular System (chest

pain/ pressure/ tightness, palpitations,
orthopnea, paroxysmal nocturnal
dyspnea, shorntness of breath,
Patient’s Name / Room No. | 1
edema, claudication, endurance, etc.)

6. Digestive System
(dysphagia, heartburn, ulcer, GERD,
indigestion, food intolerance, diarrhea,
constipation, abdominal pain, blood in
stool, black tarry stools, changes in
bowel habits, reduced caliber of
stools, hemorrhoids, etc.)
7. Excretory System
(urgency, frequency, nocturia, dysuria,
hematuria, recurrent UTIs, STD,
incontinence, etc.)

8.Musculoskeletal System (limitation

in movement, stiffness, joint pain,
swelling or redness, arthritis, muscle
spasms, muscle weakness, etc.)

9. Nervous System

10. Endocrine System

(heat/cold intolerance, weight change,
fatigue, polydepsia, polyuria,
polyphagia, changes in hair
distribution, etc.)
11. Reproductive System

Patient’s Name / Room No. | 2