Patient Review of Systems
Patient Name: Date: (mm/dd/yyyy)
Birth Date: Sex: M F Race:
Marital Status: Single Married Divorced Widowed Other
Please check if you have recently experienced any of the following:
GENERAL RESPIRATORY GI Skin / Breast
trouble sleeping cough nausea rash
always tired shortness of breath vomiting / dry heaves lesions / moles
loss of appetite breathing discomfort heartburn recurrent boils
weight loss wheezing bloating discoloring
weight gain snoring constipation irregular growth
recurrent infection sleep apnea (stop breathing- diarrhea itching
excessive thirst while sleeping) loose stools breast pain
fever CVS black / bloody stools discharge from nipples
chills chest pain rectal bleeding breast lump(s)
night sweats palpitations abdominal pain  
hot flashes discomfort in chest   NEUROLOGICAL
  calf / leg pain GU blackouts
HEENT ankle swelling excessive urination headache
hay fever   urinary urgency dizziness
sinus pain MUSCULOSKELETAL / EXREMETIES pain with urination poor balance
blurred vision swollen joints difficulty with urination memory loss
eye pain stiffness in muscles blood in urine tremors
red eyes stiffness in joints waking to urinate at night visual disturbances
watery eyes muscle aches weak stream tingling, numbness, or
itchy eyes stiff neck pelvic pain (cont.) weakness in hands or feet
hearing loss back pain irregular periods paralysis
ear pain neck pain impotence  
ear drainage   vaginal yeast infection Psychiatric
ringing in ears LYMPHATIC / HEMATOLOGIC lack of sex drive anxiety
runny nose swollen glands unable to have orgasm fear
congested nose easy bruising   depression
hoarseness free bleeder FEMALES change on behavior
swallowing pain   last pap loss of interest in hobbies
sore throat Other: last period hallucinations
Other: Other: last mamogram difficulty concentrating
Major illness / Surgeries in the last year: Significant Illnesses of Family Members
Doctor's Notes: