Microsoft word - review of systems sample.doc

[Name of Clinic]
[Name of Doctor]

Patient Name: ____________________________________________________
Date: ____________

Review of Systems

Have you had any of the following pulmonary (lung-related) issues?
□ Asthma/difficulty breathing □ COPD □ Emphysema □ Other ____________ □ None of the above
Have you had any of the following cardiovascular (heart-related) issues or procedures?
□ Heart surgeries □ Congestive heart failure □ Murmurs or valvular disease □ Heart attacks/MIs □ Heart
disease/problems □ Hypertension □ Pacemaker □ Angina/chest pain □ Irregular heartbeat □ Other ___________
□ None of the above
Have you had any of the following neurological (nerve-related) issues?
□ Visual changes/loss of vision □ One-sided weakness of face or body □ History of seizures □ One-sided decreased
feeling in the face or body □ Headaches □ Memory loss □ Tremors □ Vertigo □ Loss of sense of smell
□ Strokes/TIAs □ Other _______________ □ None of the above
Have you had any of the following endocrine (glandular/hormonal) related issues or procedures?
□ Thyroid disease □ Hormone replacement therapy □ Injectable steroid replacements □ Diabetes
□ Other ________________ □ None of the above

Have you had any of the following renal (kidney-related) issues or procedures?
□ Renal calculi/stones □ Hematuria (blood in the urine) □ Incontinence (can’t control) □ Bladder Infections
□ Difficulty urinating □ Kidney disease □ Dialysis □ Other ______________________ □ None of the above
Have you had any of the following gastroenterological (stomach-related) issues?
□ Nausea □ Difficulty swallowing □ Ulcerative disease □ Frequent abdominal pain □ Hiatal hernia □ Constipation
□ Pancreatic disease □ Irritable bowel/colitis □ Hepatitis or liver disease □ Bloody or black tarry stools
□ Vomiting blood □ Bowel incontinence □ Gastroesophageal reflux/heartburn □ Other _________ □ None of the above
Have you had any of the following hematological (blood-related) issues?
□ Anemia □ Regular anti-inflammatory use (Motrin/Ibuprofen/Naproxen/Naprosyn/Aleve) □ HIV positive
□ Abnormal bleeding/bruising □ Sickle-cell anemia □ Enlarged lymph nodes □ Hemophilia
□ Hypercoagulation or deep venous thrombosis/history of blood clots □ Anticoagulant therapy □ Regular aspirin use
□ Other _______________ □ None of the above
Have you had any of the following dermatological (skin-related) issues?
□ Significant burns □ Significant rashes □ Skin grafts □ Psoriatic disorders □ Other __________ □ None of the above
Have you had any of the following musculoskeletal (bone/muscle-related) issues?
□ Rheumatoid arthritis □ Gout □ Osteoarthritis □ Broken bones □ Spinal fracture □ Spinal surgery □ Joint surgery
□ Arthritis (unknown type) □ Scoliosis □ Metal implants □ Other ______________________ □ None of the above
Have you had any of the following psychological issues?
□ Psychiatric diagnosis □ Depression □ Suicidal ideations □ Bipolar disorder □ Homicidal ideations □ Schizophrenia
□ Psychiatric hospitalizations □ Other ____________ □ None of the above
Is there anything else in your past medical history that you feel is important to your care here? __________________________
I have read the above information and certify it to be true and correct to the best of my knowledge, and hereby authorize this office of Chiropractic to provide me with chiropractic care, in accordance with this state's statutes. If my insurance will be billed, I authorize payment of medical benefits to Gregg Friedman, DC, PLC/Arcadia Spinal Health Center for services performed. Patient or Guardian Signature _______________________________
[office street address]
[city, state, zipcode]
[office phone number]
[office fax number]
[office website]

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