Review of Systems

Main Complaint (ask also for secondary complaints)

Where is it? What is it like? How bad is it (1-10)? When did it start? How long does it last? In what setting does it occur? What makes it better or worse? Are any other symptoms associated with it? OVERALL HEALTH RATING?

Past Medical History

Childhood illnesses - Adult Illnesses - Hospitalizations - Surgical Operations - Accidents - Scars on body - Organs removed - Physical or emotional traumas - Psychiatric illnesses - Allergies to drugs, herbs, foods, or other substances.

Social History

Living situation - Significant others - Children - Work - Financial stress - Religious beliefs - Outlook on present and future

Skin

Color - Temperature - Dry/Moist/Oily - Rash - Hair - Spontaneous sweating during day/night? Other

Head

Headaches? Migraine? Fainting? History of head injury or concussion? Other

Eyes

Pain? Redness? Blurred vision? Loss of vision (partial/complete)? Last eye exam (glaucoma screen)?

Ears

Ringing or other sounds? Dizziness? Pain? Infection? Other?

Mouth and Throat

Tongue? Lips? Tonsils? Gums? Mouth ulcers? Strep? Sore throat? Swollen glands? Other?

Upper Respiratory System

Phlegm? Sinuses? Allergies? Nose bleeds? Sore throat? Swollen glands?

Lower Respiratory System

Cough? Phlegm? Pain? Sounds? Shortness of breath? Blood? Asthma? Bronchitis? Emphysema? Other?

Cardiovascular

Hypertension/Hypotension? Chest pain? Heart attack? Stroke? Arrhythmia? Tachycardia? Edema? Varicose veins? Cold extremities? Clotting disorders? Other?

Gastrointestinal?

Appetite? Food intolerance? Diarrhea? Constipation? Hemorrhoids? Bowel frequency? Stool color and consistency? Bloating? Gas? Belching? Heartburn? Ulcer? Nausea? Vomiting? Mouth ulcers? Mucous/blood in stool? Dysentery? Parasites? Hepatitis? Gall bladder disease? Other?

Urinary system

Urinary tract infection? Bladder infection? Kidney infection? Kidney/bladder stones? Water consumption? Urine color? Frequency? Urgency? Nocturia? Hematuria? STD’s? Other?

Reproductive system

Female: Last gyn exam? Menarche? Last period? Cycle length? Duration? Regularity? Cramps (before or with flow?) Light/heavy flow? Dysmenorrhea? PMS? Tampons/pads? Sexually active? Frequency? # Partners? Sexually satisfied? Pain during intercourse? STD’s? Contraception? Abortions? Vaginal discharge? Odor? Itching? Cervical cancer? Breast cancer? Miscarriage? Other?

Male: STD’s? Partner with chlamydia? Discharge? Lesions? Testicle pain/tenderness? Prostatitis? Sexually active? Frequency? # partners? Sexually satisfied? Infertility? Impotence? Premature ejaculation (i.e shorter time than you or partner would like)?

Musculoskeletal

Pain? Tension? Cramps? Injury? Joint pain? Osteo or rheumatoid? broken bones? Last osteopathic or chiropractic exam?

Nervous

Numbness? Tingling? Shooting pains? Paralysis? Dizziness? Seizures? Taste/smell? Memory loss? Stress level?

Endocrine

Heat/cold intolerance? Excessive sweating? Dry skin? Thyroid? Fever? Night sweats? Blood sugar (diabetes, hypoglycemia)? Other

Psychological

Depression? Thought of suicide? SLAP test (Specific means, Lethal, Available, Proximate)? Anxiety? Irritability? History of physical or sexual abuse (rape?) Mood swings? Addictions? Eating disorder?

Energetics?

Pulse (beats per breath)? Pulse (strong/weak)? Pulse (wide/narrow)? Pulse (surface/deep)? Tongue (broad/thin)? Tongue (red/pale)? Tongue coat (heavy, light, none)? Tongue coat (color)