3) Review of Systems Name GENERAL (check all that apply) Unexplained weight loss or gain Unexplained fatigue or weakness Loss of appetite Fever Chills Sweats n/a EYES Blurred or double vision Eye pain or redness Excessive tearing Wears glasses or contacts Bags under eyes Burning sensation Cataracts Crusty lids Dark circles Dyslexia Glaucoma Light sensitive Bloodshot Swollen lids n/a EAR / NOSE / THROAT Nose bleeds Frequent sore throat / hoarseness Hearing loss or ringing in ears Earaches or drainage Chronic sinus problem Excessive wax Itching in ear Sound sensitive Hay fever Yellow mucus Sinus trouble Bad breath Bleeding gums Bridges Canker sores Crowns Gag easily Root canals Mouth ulcers n/a RESPIRATORY Chronic or frequent coughs Loud snoring Altered breathing during sleep Wheezing Shortness of breath Spitting up blood Apnea Asthma Bronchitis Congestion Pneumonia Smoker n/a CARDIOVASCULAR Chest pain / discomfort Palpitations (fast or irregular heartbeat) Shortness of breath when walking or lying Angina Swelling of feet, ankles, or hands Cold extremities Flushing of skin n/aGASTROINTESTINAL Heartburn / reflux / indigestion Blood / change in bowel movement Constipation Nausea or vomiting Frequent diarrhea Abdominal pain Bloating or flatulence Anal itching Belching Colitis Difficulty swallowing Gallbladder trouble Hemorrhoids Mucus Ulcers Fat intolerance n/a GENITOURINARY Frequent urination Burning or painful urination Blood in urine Incontinence or dribbling Discharge: penis or vagina Kidney stones Increased nighttime urination Cystitis Hesitancy Infections Pale urine Dark yellow urine Acute renal failure Neurogenic bladder Prostate cancer Sickle cell nephropathy Urinary tract infections n/a GENITAL (MALE) Discharge Genital herpes Impotence Infertility Itching Painful urination Prostatic hypertrophy Sores Testicular pain Infection n/a GENITAL (FEMALE) Birth control pills Discharge Dysmenorrhea Endometriosis Excess hair growth Frigidity Genital herpes Hot flashes Hysterectomy Infertility Irregular cycle Itching Menopausal symptoms PMS Spotting Yeast infections Excessive bleeding n/a MUSCULOSKELETAL Neck pain Back pain Muscle / joint pain Joint stiffness or swelling Weakness of muscles or joints Finger arthritis Fibromyalgia n/aSKIN New / change in mole Rash or itching Change in hair or nails Lumps Dry skin Varicose veins Excessive thirst Acne Athlete’s foot Bruising Burning feet Cracks Dandruff Eczema Hair loss Herpes Hives Poor wound healing Redness Liver spots Oily Pale Peeling Psoriasis Warts White bumps White patches Yellow tone Ridged nails Spoon shaped nails White spots on nails Pale lips Bluish lips n/a BREAST Lump Pain Nipple discharge Tender breasts n/a NEUROLOGICAL Frequent / recurring headaches Light headed / dizziness Numbness / tingling sensations Tremors Paralysis Head injury Migraines ADD ADHD Anxiety Brain fog Confusion Delusional Depression Disoriented Excessive sleepiness Fainting Hyperactivity Impulsiveness Insomnia Mood swings Nightmares Rage behavior Seizures Speech delay Sciatica Withdrawal Autism n/a PSYCHIATRIC Anxiety / stress / irritability Lack of concentration Depression Insomnia Nervousness Hallucinations Panic attacks Mood changes Suicidal attempts Major depressive disorder Obsessive-compulsive disorder Bipolar disorder Multiple personality disorders Post traumatic stress disorder n/a ENDOCRINE Heat or cold sensitivity Excessive thirst or urination Excessive sweating Glandular or hormone problem Skin becoming drier Coarse features Excessive hunger Fatigue HRT Hyperthyroid Hypoglycemia Hypothyroid Poor carb tolerance Overweight Underweight Diabetes hx n/aCHRONIC CONDITIONS / AUTOIMMUNE DISEASES Rheumatoid arthritis Lupus Crohn’s disease Hashimoto’s thyroiditis Celiac disease Addison’s disease Graves’ disease Multiple sclerosis Scleroderma / CREST syndrome Raynaud’s disease Alopecia Endometriosis Vitiligo Type 1 diabetes Psoriasis Kawasaki disease Fibromyalgia Chronic fatigue n/a HEMATOLOGIC / LYMPHATIC Swollen glands Easy bruising Slow to heal after cuts Anemia Past transfusion Easy bleeding High blood pressure HIV / AIDS Leukemia Sickle cell disease Lymphadenopathy Lymphadenitis Splenomegaly Enlarged spleen Hypersplenism n/a ALLERGIES Medication (if so, please list) Cigarette smoke Cockroaches Cosmetic Dust mite Food allergy Grass pollen Hay fever House dust Latex Mold Pet Pollen Ragweed Trees n/a (do not prescribe) Enter Code Powered by ChronoForms - ChronoEngine.com
