Review of Systems Name First Middle Last Date of Birth MM slash DD slash YYYY Today's Date MM slash DD slash YYYY Do you now or have you had any problems related to the following? Select Now (N) or Past (P), or leave blank.Ear (N) Decreased hearing Pain Fullness Infection Ringing Dizziness Hearing Aid/s Ear (P) Decreased hearing Pain Fullness Infection Ringing Dizziness Hearing Aid/s Nose (N) Blockage/breathing Congestion Drainage Infection Trauma Sneezing Bleeding Loss of smell Nose (P) Blockage/breathing Congestion Drainage Infection Trauma Sneezing Bleeding Loss of smell Throat (N) Lumps/growth Pain Swelling Loss of voice Abscess Tonsillitis Hoarseness Voice change Throat (P) Lumps/growth Pain Swelling Loss of voice Abscess Tonsillitis Hoarseness Voice change Sinus (N) Polyps Eye/facial swelling Change in vision Pain Pressure Drainage Headaches Infection Congestion Sinus (P) Polyps Eye/facial swelling Change in vision Pain Pressure Drainage Headaches Infection Congestion Mouth (N) Sores on tongue Bad breath Lumps/growth Bleeding Pain Gums swelling Mouth (P) Sores on tongue Bad breath Lumps/growth Bleeding Pain Gums swelling Eyes (N) Redness Watery Itching Change in vision Other Eyes (P) Redness Watery Itching Change in vision Other If other, please provide details Neurological (N) Numbness/tingling Headache Tremors Dizzy spells Other Neurological (P) Numbness/tingling Headache Tremors Dizzy spells Other If other, please provide details Endocrine (N) Too hot/cold Tired/sluggish Excessive thirst Thyroid Other Endocrine (P) Too hot/cold Tired/sluggish Excessive thirst Thyroid Other If other, please provide details Gastrointestinal (N) Indigestion/heartburn Nighttime cough Abdominal pain Nausea/vomiting Other Gastrointestinal (P) Indigestion/heartburn Nighttime cough Abdominal pain Nausea/vomiting Other If other, please provide details Cardiovascular (N) Pericarditis Low blood pressure High blood pressure Chest pain Arrhythmia issues Varicose veins Cardiovascular (P) Pericarditis Low blood pressure High blood pressure Chest pain Arrhythmia issues Varicose veins Skin (N) Skin rash Boils Persistent itch Other Skin (P) Skin rash Boils Persistent itch Other If other, please provide details Musculoskeletal (N) Joint pain Neck pain Back pain Other Musculoskeletal (P) Joint pain Neck pain Back pain Other If other, please provide details Respiratory (N) Wheezing Frequent cough Shortness of breath Other Respiratory (P) Wheezing Frequent cough Shortness of breath Other If other, please provide details Hematological/lymphatic (N) Swollen glands Blood clotting problems Other Hematological/lymphatic (P) Swollen glands Blood clotting problems Other If other, please provide details Psychological/emotional (N) Medication Depression Anxiety Other Psychological/emotional (P) Medication Depression Anxiety Other If other, please provide details Allergic/immunological (N) Behavioral problems Hives Hay fever Drug allergies Food allergies Picky eater MTHFR Other Allergic/immunological (P) Behavioral problems Hives Hay fever Drug allergies Food allergies Picky eater MTHFR Other If other, please provide details Hormones (N) Low testosterone Menopause Abnormal levels Other Hormones (P) Low testosterone Menopause Abnormal levels Other If other, please provide details Δ
