Review of Systems

Question 1

Broad question for general well being

Answer 1

Have you noticed any changes in your health lately?

Question 2

Broad question for skin

Answer 2

Have you noticed any changes in your skin lately?

Question 3

Broad question for head

Answer 3

Have you had any headaches or head injuries lately?

Question 4

Broad question for eyes

Answer 4

Have you noticed any changes in your eyes or in your vision?

Question 5

Broad question for ears

Answer 5

Do you have any problems with your ears or with your hearing?

Question 6

Broad question for nose or sinus

Answer 6

Have you had any problems with your nose or sinuses?

Question 7

Broad question for mouth and pharynx

Answer 7

Have you had any tooth pain or pain in your throat?

Question 8

Broad question for neck

Answer 8

Have you noticed any swelling, pain or stiffness in your neck?

Question 9

Broad question for breasts

Answer 9

Have you noticed any lumps or pain in your breasts?

Question 10

Broad question for respiratory

Answer 10

Have you noticed any trouble with your breathing?

Question 11

Broad question for cardiovascular

Answer 11

Have you had any heart trouble, chest pain or palpitations?

Question 12

Broad question for GI

Answer 12

Have you had any problems with your appetite, nausea or diarrhea? What about abdominal pain?

Question 13

Broad question for urinary

Answer 13

Have you had any problems with urination?

Question 14

Broad question for genitals

Answer 14

Have you noticed any sexual problems or changes?

Question 15

Broad question for peripheral vascular

Answer 15

Have you noticed any leg cramping or swelling?

Question 16

Broad question for musculoskeletal

Answer 16

Have you had any pain, stiffness or problems with mobility in your joints or muscles?

Question 17

Broad question for psychiatric

Answer 17

Have you noticed any changes in your mood?

Question 18

Broad question for neurologic

Answer 18

Have you had any unexplained episodes of dizziness, seizures, fainting or blackouts?
Have you noticed any changes in your coordination?

Question 19

Broad question for hematology

Answer 19

Do you bruise or bleed easily?

Question 20

Broad question for endocrine

Answer 20

Have you noticed any changes in you thirst, hunger or tolerance to hot and cold?