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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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