Review of Systems

Question 1

General

Answer 1

Current weight and any recent change; weakness, fatigue; fever; energy level.

Question 2

Endocrine

Answer 2

History of thyroid disease; history of high blood sugar; recent intolerance
to heat or cold; excessive thirst, hunger, or volume of urine output.

Question 3

Hemotologic

Answer 3

History of anemia; easy bruising or difficulty controlling bleeding; history of blood transfusions including dates, reactions to blood products; history of blood clots or anticoagulation.

Question 4

Psychiatric

Answer 4

History of treatment for psychiatric or emotional problems; nervousness; anxiety; undue sadness; sleep disturbance; death wishes or suicidal thoughts.

Question 5

Skin

Answer 5

Recent changes in texture or appearance of hair, skin, or nails; new rashes, lumps, sores; history of treatment for skin condition.

Question 6

Head

Answer 6

Any headache, head injury

Question 7

Eyes

Answer 7

Recent change in vision; blurring of vision; double vision; red or painful eyes;
history of glaucoma or cataracts; most recent eye examination and results.

Question 8

Ears

Answer 8

Recent change in hearing; pain in or drainage from ears; ringing in the ears; dizziness with or without changes in head position.

Question 9

Nose and Sinuses

Answer 9

Increase in frequency of colds or nasal drainage; nosebleeds; history of sinus infections.

Question 10

Mouth, throat, teeth:

Answer 10

Sores of tongue or mouth; dental problems and dental care history; bleeding of gums; hoarseness or voice change.

Question 11

Neck

Answer 11

Stiffness or injury; new lumps or swelling.

Question 12

Breasts

Answer 12

Tenderness; lumps; nipple discharge; history of self-examination; last physician
examination and/or mammogram; any prior aspiration or biopsy.

Question 13

Cardiac/blood vessels

Answer 13

History of high blood pressure; heart disease; heart murmur; palpitations; chest pain or pressure; shortness of breath on exertion or while lying down; ankle swelling; history of electrocardiogram, chest x-ray, or other diagnostic tests; pain in legs with walking (how far); sensitivity or color change in fingers or toes with cold temperatures; varicose veins or history of phlebitis.

Question 14

Respiratory

Answer 14

History of asthma, bronchitis, pneumonia, pleurisy, tuberculosis; new cough, sputum, coughing blood, wheezing or shortness of breath.

Question 15

Gastrointestinal

Answer 15

Difficulty swallowing, change in appetite; nausea, vomiting; diarrhea; abdominal pain, vomiting blood, or blood in stool; constipation or recent change in bowel habits or appearance of stool; history of jaundice, liver or gallbladder problems; indigestion or new food intolerance.

Question 16

Urinary

Answer 16

Change in frequency of urination, volume of urine, or nature of stream; burning on urination; blood in urine; hesitancy; urgency; incontinence; history of urinary
infections or stones; nocturia.

Question 17

Male Genitoreproductive

Answer 17

History of hernia; venereal diseases; sores on penis; pain in testicle; frequency of testicular self-examination; sexual orientation, function, satisfaction, or concerns if not raised and covered adequately in earlier portions of the history.

Question 18

Female Genitoreproductive General

Answer 18

Menstrual history, including age of menarche, cycle
length, pain with menses, change in duration, amount, or frequency of menses (may be omitted in the postmenopausal woman).

Question 19

Female Genitoreproductive Older Women

Answer 19

For the older woman, history of age and any difficulty with menopause such as hot flashes, irregular bleeding; history of hormone therapy, postmenopausal vaginal bleeding.

Question 20

Female Genitoreproductive All Postmenarcheal

Answer 20

For all postmenarcheal women, history of venereal disease, vaginal discharge, painful sexual intercourse, vulvar itching, or unexpected vaginal bleeding. Sexual orientation, activity, satisfaction, and concerns if they have not been discussed during other portions of the history. If not obtained earlier, the history of pregnancy and delivery, birth control method(s), and concerns about reproductive health may be asked at this time.

Question 21

Musculoskeletal

Answer 21

Muscle weakness, pain, tenderness, or stiffness; pain or swelling in joints; history of arthritis, gout, or back pain.

Question 22

Neurologic

Answer 22

History of seizures, blackouts; paralysis; numbness or tingling; trembling or weakness; difficulty speaking; memory loss or difficulty concentrating.

Question 23

Sleep

Answer 23

Difficulty getting to sleep, staying asleep; poor quality/non-restorative sleep; fall asleep or become severely drowsy while driving, reading, watching television, attending meetings or lectures; snore heavily or stop breathing in sleep, awakening with gasp, short of breath; morning headache.