Pondworks Review of Systems
If you are not having any difficulties, please check "No Problems." If you are experiencing any of the symptoms listed, please specify in the "comments" box the one(s) that apply, or explain any that may not be listed. If you have any questions, please ask your provider.
1. Constitution (health in general): problem(s)?
problem(s) with lack of energy, unexplained weight gain or loss, loss of appetite, fever, night sweats, pain in jaws when eating, scalp tenderness, prior diagnosis of cancer
2. Ears, nose, mouth & throat problems?
problem(s) with hearing, sinus problems, runny nose, post-nasal drip, ringing in ears, mouth sores, loose teeth, ear pain, nosebleeds, sore throat, facial pain or numbness
3. Cardiovascular problems (heart & blood vessels)?
problem(s) with irregular heartbeat, racing heart, chest pains, swelling of feet or legs, pain in legs with walking
4. Respiratory problems (lungs & breathing)?
problems with shortness of breath, night sweats, prolonged cough, wheezing, sputum production, prior tuberculosis, pleurisy, oxygen at home, coughing up blood, abnormal chest x-ray
5. Gastrointestinal problems (stomach & intestines)?
problems with heartburn, constipation, intolerance to certain foods, diarrhea, abdominal pain, difficulty swallowing, nausea, vomiting, blood in stools, unexplained changes in bowel habits, incontinence
6. Urological problems (kidney & bladder)?
problems with painful urination, frequent urination, urgency, prostate problems, bladder problems, impotence
7. Musculoskeletal problems (muscles, bones & joints)?
problems with joint pain, aching muscles, shoulder pain, swelling of joints, joint deformities, back pain
8. Integumentary problems (skin, hair & breast)?
problems with persistent rash, itching, new skin lesion, change in existing skin lesion, hair loss or increase, breast changes
9. Neurological problems (brain & nerves)?
problems with frequent headaches, double vision, weakness, change in sensation, problems with walking or balance, dizziness, tremor, loss of consciousness, uncontrolled motions, episodes of visual loss
10. Endocrinologic problems (glands)?
problems with intolerance to heat or cold, menstrual irregularities, frequent hunger/urination/thirst, changes in sex drive
11. Hemotologic problems (blood & lymph)?
problems with easy bleeding, easy bruising, anemia, abnormal blood tests, leukemia, unexplained swollen areas
12. Allergic/immunologic problems?
problems with seasonal allergies, hay fever symptoms, itching, frequent infections, exposure to HIV