REVIEW OF SYSTEMS
SKIN                                 Nipple discharge                   Clots in veins
  Rashes                             BSE
  Itching                                                           MUSCULOSKELETAL
  Change in hair or nails        RESPIRATORY/CARDIAC                  Pain
                                    Shortness of breath               Swelling
HEAD                                Cough                             Stiffness
  Headaches                          Production of phlegm, color      Decreased joint motion
  Head injury                        Wheezing                         Broken bone
                                     Coughing up                      Serious sprains
EYES                                 blood Chest pain
                                                                      Arthritis
                                     Fever
    Glasses or contacts                                               Gout
                                     Night sweats
    Change in vision                 Swelling in hands/feet         NEUROLOGIC
    Eye pain                         Blue fingers/toes                Headaches
    Double vision                    High blood pressure              Seizures
    Flashing lights                  Skipping heart beats              Loss of
    Glaucoma/Cataracts               Heart murmur                   Consciousness/Fainting
    Last eye exam                    HX of heart Medication             Paralysis
                                     Bronchitis/emphysema               Weakness
EARS                                 Rheumatic heart disease            Loss of muscle size
  Change in                                                             Muscle spasm
  Hearing Ear pain               GASROINTESTINAL
                                                                        Tremor
  Ear discharge                    Change of appetite or
                                                                        Involuntary movement
  Ringing                        Weight
                                                                        Incoordination
  Dizziness                         Problems swallowing
                                                                        Numbness
                                    Nausea                             Feeling of “pins and
NOSE/SINUSES                        Heartburn                       needles/tingles”
  Nose bleeds                       Vomiting
  Nasal stuffiness                  Vomiting blood                  HEMATOLOGIC
  Frequent colds                    Constipation                      Anemia
                                    Diarrhea                            Easy bruising/bleeding
ALLERGIES                           Change in bowel habits              Past Transfusions
   Hives                            Abdominal pain
    Swelling of lips or tongue                                      ENDOCRINE
                                     Excessive belching
    Hay fever                        Excessive flatus                 Abnormal growth
    Asthma                            Yellow color of skin            Increased appetite
    Eczema/Sensitive             (jaundice/hepatitis)                 Increased thirst
   Sensitivity to drugs, food,     Food intolerance                    Increased urine production
pollens, or dander                 Rectal bleeding/                     Thyroid trouble
                                 Hemorrhoids                            Heat/cold intolerance
MOUTH/THROAT                                                            Excessive sweating
                                 URINARY                                Diabetes
    Bleeding gums                   Difficulty in urination
    Sore tongue                      Pain or burning on urination   PSYCHIATRIC
    Sore throat                      Frequent urination at night      Tension/Anxiety
    Hoarseness                       Urgent need to                     Depression/suicide ideation
                                     urinate Incontinence               Memory problems
NECK                                 of urine Dribbling                 Unusual problems
  Lumps                              Decreased urine stream             Sleep problems
  Swollen glands                     Blood in urine                    Past treatment with
  Goiter                             UTI/stones/prostate            Psychiatrist
  Stiffness                      infection                             Change in mood/change in
                                                                    attitude towards family/friends
BREAST
  Lumps                          PERIPHERAL VASCULAR
  Pain                             Leg cramps
                                     Varicose veins