Review of Systems(Include both past and current health problems. Comment on all present issues.) |
General Health State (present weight – gain or loss, reason for gain or loss, amount of time for gain or loss; fatigue, malaise, weakness, sweats, night sweats, chills ): |
Skin (history of skin disease, pigment or color change, change in mole, excessive dryness or moisture, pruritis, excessive bruising, rash or lesion):Health Promotion (Sun exposure? Skin care products?): |
Hair (recent loss or change in texture):Health Promotion (method of self-care, products used for care): |
Nails (change in color, shape, brittleness):Health Promotion (method of self-care, products used for care): |
Head (unusual headaches, frequency of headaches, head injury, dizziness, syncope or vertigo): |
Eyes (difficulty or change in vision, decreased acuity, blurring, blind spots, eye pain, diplopia, redness or swelling, watering or discharge, glaucoma or cataracts):Health Promotion (wears glasses or contacts and reason, last vision check, last glaucoma check, sun protection): |
Ears (earaches, infections, discharge and its characteristics, tinnitus or vertigo):Health Promotion (hearing loss, hearing aid use, environmental noise exposure, methods for cleaning ears): |
Nose and Sinuses (discharge and its characteristics, frequent or severe colds, sinus pain, nasal obstruction, nosebleeds, seasonal allergies, change in sense of smell):Health Promotion (methods for cleaning nose): |
Mouth and Throat (mouth pain, sore throat, bleeding gums, toothache, lesions in mouth, tongue, or throat, dysphagia, hoarseness, tonsillectomy, alteration in taste):Health Promotion (Daily dental care – brushing, flossing. Use of prosthetics – bridges, dentures. Last dental exam/check-up.): |
Neck (pain, limitation of motion, lumps or swelling, enlarged or tender lymph nodes, goiter): |
Neurologic System (history of seizure disorder, syncopal episodes, CVA, motor function or coordination disorders/abnormalities, paresthesia, mood change, depression, memory disorder, history of mental health disorders):Health Promotion (activities to stimulate thinking, exam related to mood changes/depression): |
Endocrine System (history of diabetes or insulin resistance, history of thyroid disease, intolerance to heat or cold):Health Promotion (last blood glucose test and result, diet): |
Breast and Axilla (pain, lump, tenderness, swelling, rash, nipple discharge, any breast surgery):Health Promotion (performs breast self-exam – both male and female, last mammogram and results, use of self-care products): |
Respiratory System (History of lung disease, smoking, chest pain with breathing, wheezing, shortness of breath, cough – productive or nonproductive. Sputum – color and amount. Hemoptysis, toxin or pollution exposure.):Health Promotion (last chest x-ray, smoking cessation): |
Cardiac System (history of cardiac disease, MI, atherosclerosis, arteriosclerosis, chest pain, angina):Health Promotion (last cardiac exam): |
Peripheral Vascular System (coldness, numbness, tingling, swelling of legs/ankles, discoloration of hands/feet, varicose veins, intermittent claudication, thrombophlebitis or ulcers):Health Promotion (avoid crossing legs, avoid sitting/standing for long lengths of time, promote wearing of support hose): |
Hematologic System (bleeding tendency of skin or mucous membranes, excessive bruising, swelling of lymph nodes, blood transfusion and any reactions, exposure to toxic agents or radiation):Health Promotion (use of standard precautions when exposed to blood/body fluids): |
Gastrointestinal System (appetite, food intolerance, dysphagia, heartburn, indigestion, pain [with eating or other], pyrosis, nausea, vomiting, history of abdominal disease, gastric ulcers, flatulence, bowel movement frequency, change in stool [color, consistency], diarrhea, constipation, hemorrhoids, rectal bleeding):Health Promotion (nutrition – quality/quantity of diet; use of antacids/laxatives): |
Musculoskeletal System (history of arthritis, joint pain, stiffness, swelling, deformity, limitation of motion, pain, cramps or weakness):Health Promotion (mobility aids used, exercises, walking, effect of limited range of motion): |
Urinary System (recent change, frequency, urgency, nocturia, dysuria, polyuria, oliguria, hesitancy or straining, urine color, narrowed stream, incontinence; history of urinary disease; pain in flank, groin, suprapubic region or low back):Health Promotion (methods used to prevent urinary tract infections, use of feminine hygiene products, Kegel exercises): |
Male Genital System (penis or testicular pain, sores or lesions, penile discharge, lumps, hernia):Health Promotion (performs testicular self-exam): |
Female Genital System (menstrual history, age of first menses, last menstrual cycle, frequency of cycles, premenstrual pain, vaginal itching, discharge, premenopausal symptoms, age at menopause, postmenopausal bleeding):Health Promotion (last gynecological checkup, pap-smear and results, use of feminine hygiene products): |
Sexual Health (presently involved in relationship involving intercourse or other sexual activity, aspects of sex satisfactory, use of contraceptive, is relationship monogamous, history of STD):Health Promotion (safe-sex practices): |