Review of Systems                                                 Pg 3/3
(circle "yes" or "no" on each)
General Cardiovascular
I always worry about my health yes no I often have chest tightness or pressure yes no
I am always tired or worn out yes no My chest pain has worsened lately yes no
I am always cold when other are not yes no My chest hurts when I exert myself yes no
I often don't feel like eating yes no My ankles are always swollen yes no
I often have fever yes no My heart often beats fast or skips beats yes no
I often have chills yes no I often feel faint or lightheaded yes no
Clothes are often wet from night sweats yes no My legs always hurt during walking yes no
I am always short of breath when lying flat yes no
Emotional
I often feel depressed yes no Genitourinary
I consider myself a nervous person yes no I often have penile or vaginal drainage yes no
I often cry for no reason yes no I often have problems with my erections yes no
I have had urges to commit suicide yes no I often have pain during sexual relations yes no
I often have difficulty sleeping yes no I often hurt or burn when I urinate yes no
I urinate more than once a night yes no
Skin I urinate much more often than I used to yes no
My skin often itches yes no I often leak urine when I cough or sneeze yes no
My skin is always dry yes no My urine is often bloody yes no
My skin has changed color yes no
I have a skin rash yes no Neurological
I have sores that won't heal yes no I often have severe headaches yes no
I am often dizzy (spinning around) yes no
Eyes I often have double vision yes no
My eyes are always dry yes no My memory has become VERY poor yes no
My vision is always blurry yes no I often lose my balance yes no
My eyes always hurt yes no I have blacked-out recently yes no
Ear/Nose/Throat Hematological
I can't hear well yes no I often have severe nose bleeds yes no
My ears always ring yes no My gums often bleed yes no
My ears always hurt yes no I now bruise very easily yes no
My nose is always stuffy or congested yes no I was told that I am anemic recently yes no
I always have drainage down my throat yes no
My tongue is always sore yes no Female
I am still having my menses (periods) yes no
Repiratory I am still able to have children yes no
I always have a cough yes no I am using some sort of birth control yes no
I often cough up blood yes no
I often cough up green/yellow mucus yes no Musculoskeletal
I am often short of breath yes no My joints are often swollen and red yes no
I often wheeze yes no My ankles always hurt yes no
My chest hurts when breathing/coughing yes no My muscles always hurt yes no