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Review of Systems

Introduction 3. Any hay fever?


1. "In this next part, I'm going to ask you a series of 4. Any nosebleeds?
questions about your health. It might seem like a
lot, but the questions are important and I want to
Throat (mouth, pharynx)
1. How are your teeth and gums?
make sure I'm being thorough" (or some
2. Any bleeding gums?
variation)
3. Do you use dentures (if so, how do they fit)
4. When was your last dental examination?
5. Has your tongue been sore?
General 6. Any problems with dry mouth?
1. What's your usual weight? 7. Have you had frequent sore throats or
◦ Any recent weight changes? hoarseness?
◦ Any clothes that fit more tightly or loosely than
before? Neck
2. Any weakness, fatigue, or fever? 1. Any swollen glands?
2. Have you ever had a goiter?
3. Any lumps, pain, or stiffness in the neck?
Skin
1. Any rashes, lumps or sores?
2. Any itching, dryness, or changes in skin color? Breasts
3. Any changes in hair or nails? 1. Any lumps, pain, or discomfort?
4. Any changes in size or color of moles? 2. Any nipple discharge?
3. Do you practice the breast self-examination? How
often?
HEENT
Head Respiratory
1. Any headache, dizziness, or lightheadedness? 1. Any coughing? Anything coming up in the cough
2. Any recent head injury? (sputum: color, quantity). Any blood in your
cough (hemoptysis)?
Eyes 2. Any shortness of breath (dypsnea), or wheezing?
1. Any changes or problems in your vision? (also pleurisy)
2. Do you use glasses or contact lenses? 3. When was your last chest X-ray?
When was your last eye exam? 4. Optional: Any history of lung disease (asthma,
3. Any pain, redness, or excessive tearing? bronchitis, emphysema, pneumonia, or
4. Any double or blurred vision? tuberculosis?)
5. Any spots, specks, or flashing lights?
6. Have you ever been told you have glaucoma or
cataracts?
Cardiovascular
Ears 1. Any heart trouble?
1. Any problems or changes in your hearing? 2. Ever been told you have high blood pressure or
2. Any ringing (tinnitus) or vertigo? heart murmurs?
3. Any earaches, infections, or discharge? 3. Any history of rheumatic fever?
4. Any chest pain or discomfort?
Nose 5. Any palpations, shortness of breath (dyspnea)
1. Any frequent colds or sinus trouble? 6. Any trouble breathing when you're laying down
2. Any nasal stuffiness, discharge, or itching? (orthopnea), or sleeping (paroxysmal nocturnal
dyspnea)?
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Review of Systems
7. Any swelling (edema)? Genital
8. Have you ever had an electrocardiogram (EKG) or
another cardiovascular test? What was it / when Male
was it / what were the results? 1. Any hernias?
2. Any discharge from or sores on the penis?
3. Any testicular pain or lumps/masses?
Gastrointestinal 4. Any pain or swelling in your scrotum?
5. Have you ever had a sexually transmitted disease
Appetite & eating (history & Tx)
1. Any trouble swallowing, heartburn, or nausea? 6. Are you sexually active? With whom? (sexual
2. Any changes in your appetite? habits, interest, function, satisfaction, birth
3. Any problems with food intolerance? control, condom use, problems)
7. Have you ever been or think you might have been
Bowel movements exposed to HIV? Via drug use, sexual contact, or
1. Any changes in your bowel habits or pain when another way?
defecating?
2. How have your bowel movements been? How Female
would you describe your stool color and size Menstruation:
recently? 1. When did you have your first period (age at
3. Any blood in your stool, or black or tarry stools? menarche)
4. Any hemorrhoids? 2. How often does your period come? Is it regular?
5. Any constipation or diarrhea? How long do they last?
3. Would you describe your period as especially
Other heavy or light?
1. Any abdominal pain? 4. Any bleeding between your periods or after
2. Any excessive belching, or passing of gas? intercourse?
3. Have you noticed any yellowing of your skin 5. When was your last period?
(jaundice). 6. Any pain during your period (dysmenorrhea)?
4. Ever been told you have liver or gallbladder 7. Any changes in mood or how you feel before your
trouble or hepatitis? period?
8. If applicable: when did you begin menopause?
Have you had any symptoms during menopause?
Urinary Have you had any bleeding since menopause?
1. Any changes or problems with how often you
have to urinate? Other Gyn:
2. Are you urinating more than normal (polyuria) or 1. Any vaginal discharge?
at night (nocturia)? 2. Any itching, sores, or lumps?
3. Any problems with urgency, incontinence, 3. Have you ever had a sexually transmitted disease
burning, or pain when urinating? (history & Tx)
4. Any blood in your urine (hematuria)?
5. Any urinary infections? OB:
6. Any pain in your kidneys or flanks? 1. Have you ever been pregnant? How many times?
7. Any history of kidney stones? 1. How many children have you delivered?
8. Any pain above your genitals (suprapubic) or in 2. Any miscarriages or abortions?
that area (sharp pain could be uretral colic) 3. Any complications during pregnancy?
9. Males: any change in the force or width of your 2. Do you use birth control? What kind?
urinary stream? Any hesitancy or dribbling? 3. Are you sexually active? With whom? (interest,
function, satisfaction, any problems?). Any
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Review of Systems
pain during intercourse (dyspreunia)? 4. Any headache, dizziness, or vertigo?
4. Have you ever been or think you might have been 5. Any fainting, blackouts, or seizures?
exposed to HIV? Via drug use, sexual contact, 6. Any weakness, paralysis, numbness or loss of
or another way? sensation?
5. If patient born before 1971: Any exposure to 7. Any feelings of tingling or "pins and needles"?
diethylsilbestrol (DES) from maternal use during 8. Any tremors or other involuntary movements?
pregnancy? 9. Have you ever had a seizure?

Peripheral Vascular: Hematologic


1. Any muscle pain (intermittent claudication), or leg 1. Any history of anemia?
cramps? 2. Do you bruise or bleed easily?
2. Any varicose veins? 3. Have you ever had any transfusion (if yes,
3. Have you ever had clots in your veins? reactions to transfusions)
4. Any swelling in your calves, legs, or feet?
5. Any changes in the color of your fingertips or toes
during cold weather? Endocrine
6. Any swelling with redness or tenderness? 1. Have you ever had thyroid trouble? Any
intolerance to heat or cold?
2. Any excessive sweating, thirst, or hunger
Musculoskeletal 3. Any excessive urination?
1. Any muscle or joint pain? 4. Any changes in glove or shoe size?
2. Any stiffness, arthritis, or gout?
3. Any back pain?
4. Any pain in your neck or lower back?
5. Any joint pain with fever, chills, rash, loss of
appetite (anorexia), weight loss, or weakness?
6. If present,
1. Describe location of affected joints/muscles,
swelling, rendess, pain, tenderness, stiffness,
weakness, limitations of motions or activity
2. Give PQRST & history of trauma if applicable

Psychiatric
1. Have you been feeling nervous or tense recently?
2. How's your mood been?
3. Have you had any problems with your memory?
4. Have you been feeling depressed / suicide
attempts (if relevant)

Neurologic
1. Any changes in mood, attention, or speech?
2. Any changes in memory, judgment, or insight?
3. Have you ever become disoriented, lost track of
where you were, or what time it was?