Review of Systems Template

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R"E"V"I"E"W"""""O"F""""S"Y"S"T"E"M"S"

CONSTITUTIONAL:"fever,&chills,&weight&loss&or&gain,&weakness&EYES:"vision&loss,&vision&change,&pain,&double&vision,&redness,&glasses&or&contacts,&glaucoma,&cataracts,&last&

eye&doctor&appointment&

ENT!EARS:!hearing&changes,&ringing&in&ears,&dizziness,&discharge,&pain!NOSE:!congestion,&runny&nose,&sinus&pain,&allergies&

THROAT:"sore&throat,&hoarseness,&voice&changes,&mouth&sores,&dentures,&last&dental&visit&CARDIOVASCULAR:!chest&pain&or&discomfort,&tightness,&palpitations,&racing&heart,&short&of&breath&with&

activity,&difficulty&breathing&lying&down,&swelling,&sudden&awakening&from&sleep&short&of&breath,&high&blood&pressure,&high&cholesterol,&heart&attack,&leg&cramping&&

RESPIRATORY:!cough,&sputum,&coughing&up&blood,&wheezing,&short&of&breath,&painful&breathing&

GASTROINTESTINAL:"problems&swallowing,&heartburn,&indigestion,&change&in&appetite,&nausea,&vomiting,&diarrhea,&constipation,&change&in&bowel&habits,&blood&in&stool,&last&colonoscopy!

FEMALE!GENITOURINARY:!urinary&frequency,&urgency,&incontinence,&burning&or&pain,&blood&in&urine.&Vaginal&discharge,&pain&with&intercourse,&date&of&last&menstrual&cycle,&sexual&practices,&OB&history&@GTPAL=&gestation,&term,&preterm,&abortion,&living&

MALE!GENITOURINARY:&decreased&force&of&urine&stream,&hesitance,&frequency,&urinating&at&night,&penile&discharge,&erectile&dysfunction,&change&in&libido,&sexual&practices&

MUSCULOSKELETAL:!muscle&or&joint&pain,&stiffness,&back&pain,&redness&or&swelling&of&joints,&injuries,&any&joint&replacement&surgeries&

INTEGUMENTARY:"(breast/skin)"rashes,&lumps,&itching,&hair&or&nail&changes,&changing&or&new&moles,&breast&pain,&breast&lumps,&breast&changes"

NEUROLOGICAL:"headache,&head&injury,&dizziness,&fainting,&seizures,&tremor,&tingling,&numbness,&memory&loss,&balance&problems,&falls&

PSYCHIATRIC:&depression,&anxiety,&stress,&nervousness,&excessive&worry,&decreased&need&for&sleep,&diminished&interest&in&activities,&feelings&of&hopelessness,&suicidal&or&homicidal&thoughts&

ENDOCRINE:!heat&or&cold&intolerance,&sweating,&frequent&urination,&unexplained&weight&loss,&excessive&hunger&or&thirst&

HEMATOLOGIC/LYMPHATIC:!easy&bruising,&excessive&bruising,&easy&bleeding,&anemia,&blood&disease,&&&cancer,&enlarged&glands&or&lymph&nodes,&blood&transfusions&

ALLERGIC/IMMUNOLOGIC:!eczema,&medication&or&environmental&allergies,&hives,&hay&fever,&rheumatoid&arthritis,&lupus,&psoriasis&

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