Systems Review Patient Name: Date: Circle any conditions that are presently causing you a problem. Underline those that have caused you problems in the past. GENERAL SYMPTOMS RESPIRATORY GENITOURINARY Fever Chronic cough Frequent urination Sweats Spitting up phlegm Painful urination Fainting Spitting up blood Blood in urine Sleep disturbance Chest pain Pus in urine Fatigue Wheezing Kidney infection Nervousness Difficulty breathing Prostate trouble Weight loss Asthma Uncontrollable urine flow Weight gain NEUROLOGICAL CARDIOVASCULAR GASTROINTESTINAL Visual disturbance Rapid beating heart Poor appetite Dizziness Slow beating heart Difficult digestion Fainting High blood pressure Heartburn Convulsions Low blood pressure Ulcers Headache Pain over heart Nausea Numbness Hardening of arteries Vomiting Neuralgia (nerve pain) Swollen ankles Constipation Poor coordination Poor circulation Diarrhea Weakness Palpitations Blood in stool Cold hand or feet Gallbladder/jaundice Varicose veins Colitis EYES, EARS, NOSE, THROAT MUSCLE & JOINT FOR WOMEN ONLY Eye pain Neck pain Painful menstruation Double vision Low back pain Hot flashes Ringing in ears Arm pain Irregular cycle Deafness Shoulder pain Cramps or back pain Nosebleeds Leg pain Vaginal discharge Trouble swallowing Knee pain Nipple discharge Hoarseness Foot pain Lumps in breast Sinus infection Pain/numbness down arms or Menopausal symptoms Nasal drainage legs Birth control pills Enlarged glands Pain between shoulders swollen Miscarriages joints Complications with pregnancy Spinal curvature Pregnant? Y / N Week? Arthritis Other: Fractures
Systems Review Patient Name: Date: Circle any conditions that are presently causing you a problem. Underline those that have caused you problems in the past. GENERAL SYMPTOMS RESPIRATORY GENITOURINARY Fever Sweats Fainting Sleep disturbance Fatigue Nervousness Weight loss Weight gain Chronic cough Spitting up phlegm Spitting up blood Chest pain Wheezing Difficulty breathing Asthma Frequent urination Painful urination Blood in urine Pus in urine Kidney infection Prostate trouble Uncontrollable urine flow NEUROLOGICAL CARDIOVASCULAR GASTROINTESTINAL Visual disturbance Dizziness Fainting Convulsions Headache Numbness Neuralgia (nerve pain) Poor coordination Weakness Rapid beating heart Slow beating heart High blood pressure Low blood pressure Pain over heart Hardening of arteries Swollen ankles Poor circulation Palpitations Cold hand or feet Varicose veins Poor appetite Difficult digestion Heartburn Ulcers Nausea Vomiting Constipation Diarrhea Blood in stool Gallbladder/jaundice Colitis EYES, EARS, NOSE, THROAT MUSCLE & JOINT FOR WOMEN ONLY Eye pain Double vision Ringing in ears Deafness Nosebleeds Trouble swallowing Hoarseness Sinus infection Nasal drainage Enlarged glands Neck pain Low back pain Arm pain Shoulder pain Leg pain Knee pain Foot pain Pain/numbness down arms or legs Pain between shoulders swollen joints Spinal curvature Arthritis Fractures Painful menstruation Hot flashes Irregular cycle Cramps or back pain Vaginal discharge Nipple discharge Lumps in breast Menopausal symptoms Birth control pills Miscarriages Complications with pregnancy Pregnant? Y / N Week? Other:
Systems_Review_Form-ACAC.docx