| 0: No problems |
Ex: Excellent |
G: Good |
P: Poor |
Pain/Fatigue scale: 0-10 (words) |
|
|
| Name: ________________________________ |
Date: _______________________________ |
|
| Reason for visit: |
Ht: |
Wt: |
BP: |
| |
HR: |
Temp: |
RR: |
|
| |
| Review of systems: |
| 1. General: |
a) Physical well being |
b) Emotional - stress, anxiety, depression |
c) Fever |
|
| d) Fatigue |
e) weight gain/weight loss |
f) sleep |
g) snoring |
h) Headache |
|
| 2. |
a) Eye/vision |
b) Ear |
c) Nose |
d) Throat |
|
| 3. Cardiovascular: |
a) Chest pain |
b) palpitation |
c) Raynaud's phenomenon |
|
| 4. Respiratory: |
a) Shortness of breath |
b) Cough |
c) Expectoration/ hemoptysis |
|
| 5. GI: |
a) Appetite |
b) Nausea |
c) Heartburn |
d) Flatulance |
e) Abdominal pain |
f) Bowel movements |
|
| 6. GU |
a) Urination: |
i) Incontinence |
ii) Frequency |
iii) Nocturia |
iv) Hematuria |
|
| 7. Sexual: |
a) Impotence |
b) Decreased Libido |
c) Dysperaunea |
8. Menstruation : |
|
| 9. Neuro: |
a) Forgetfulness |
b) Confusion |
c) Speech difficulty |
d) Vertigo |
e) Dysequillibrium |
|
| f) Focal weakness |
g) Paresthesia |
h) Loss of sensation |
i) Tremor |
|
| 10. Extremities: |
a) Edema |
b) Claudication |
c) Nails |
d) Varicosities |
e) Ischemic pain |
f) Ulcers |
|
| 11. Museulo Skeletal: |
a) Muscles |
b) Joints |
c) Back |
12. Skin |
|
| ____________________________________________________________________________________ |
| |
| S: |
Abnormal findings: |
| O: |
Diagnosis: |
| A: |
Recommendations: |
|
