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Review of Systems

This form is necessary to fill out accurately so as to get a complete and detailed record of you as a patient
(please do not miss any fields).

***All of your information is kept strictly confidential.***

Vaughan Medical Centre, 9200 Weston Rd, Woodbridge, ON, L4H 2P8 (905) 417-2273 (CARE)

General:

 

First Name: Last Name:
Home Phone Number:    

Weight:
Weight one year ago:
Maximum weight:
Height: Feet Inches
Last physical exam: / / (mm/dd/yy)


Please take a brief moment to click through this image (right) which represents the anatomy of your body and remind yourself where you may (physically) be having problems right now. It will help you fill out this form.

NOTE: If you don't know what some of the words mean in the form below, leave it blank and remember to ask your doctor at your appointment time.

Remember, the more detailed you can be, the better!

 

 


Y - A condition you have now

N - A condition you have NEVER had

P - A condition you have had in the past

(* Please indicate with a check mark in the appropriate boxes below)

General:
Y
N
P
Findings (responses and comments)
         
Fatigue/Weakness
Fever/Chills
         
Skin:
Y
N
P
Findings (responses and comments)
         
Rashes
Eczema
Acne
Boiling
Itching
Color change
Lumps
Night sweats
Dryness
Moistness
Temperature
Nail changes
Changes in mole(s)
Skin cancer
Hives
Excess perspiration
Scaling
Difficulty growing nails
Warts
Dry hair
Falling/thinning hair
         
Head:
Y
N
P
Findings (responses and comments)
         
Headache
Head injury
Dizziness
Vertigo
Migraines
Pulsations
         
Eyes:
Y
N
P
Findings (responses and comments)
         
Impaired vision
Glasses/Contacts
Eye pain
Tearing
Dryness
Double vision
Glaucoma
Cataracts
Blurring
Bothered by sun/light
Itching
Redness
Discharge
Blind spot
Near/Far sighted
         
Ears:
Y
N
P
Findings (responses and comments)
         
Impaired hearing
Earache
Dizziness
Discharge
Infections
Ringing
Buzzing
Redness
         
Nose and Sinuses:
Y
N
P
Findings (responses and comments)
         
Frequent colds
Nose bleeds
Stuffiness
Hay fever
Sinus problems
Discharge
Obstruction
Loss of smell
         
Mouth and Throat:
Y
N
P
Findings (responses and comments)
         
Frequent sore throat
Sore tongue/mouth
Gum problems
Hoarseness
Dental cavities
Loss of taste
Dry/cracked/chapped lips
Cankers
         
Neck:
Y
N
P
Findings (responses and comments)
         
Lumps
Swollen glands/lymph
Goiter
Pain or stiffness
Difficulty swallowing
         
Respiratory:
Y
N
P
Findings (responses and comments)
         
Cough
Sputum/mucous
Spitting up blood
Wheezing
Asthma
Bronchitis
Pneumonia
Pleurisy
Emphysema
Difficulty breathing
Pain on breathing
Shortness of breath
Shortness of breath at night
Shortness of breath lying down
Tuberculosis
Tuberculin test
Chest x-ray
         
Cardiovascular:
Y
N
P
Findings (responses and comments)
         
Heart disease
Angina
High blood pressure
Murmurs
Rheumatic fever
Chest pain
Swelling in ankles
Palpitations/fluttering
Hear your heart beating
Cyanosis
ECG
Heart testing
Pain in chest on exertion
Blue lips
         
Peripheral:
Y
N
P
Findings (responses and comments)
         
Deep leg pain
Cold hands/feet
Varicose veins
Thrombophlebitis
Leg cramps
Numbness
Coldness
Swelling
Ulcers
         
Gastrointestinal:
Y
N
P
Findings (responses and comments)
         
Trouble swallowing
Heartburn
Change in thirst
Change in appetite
Nausea
Vomiting
Vomiting blood
Regular bowel movements- how often?
Recent changes in bowel movements
Blood in stool- bright red or rusty brown?
Belching or passing gas
Jaundice (yellow skin or white of eyes)
Liver disease
Gall bladder disease
Ulcer
Indigestion
Diarrhea
Rectal bleeding
Hemmorhoids
Black, tarry stool
Abdominal pain
Food allergy
Hernias
Hunger after eating
         
Urinary:
Y
N
P
Findings (responses and comments)
         
Pain on urination
Increased frequency
Frequency at night
Inability to hold urine
Frequent infections
Kidney stones
Blood in urine
Urgency
Hesitancy
         
Male concerns:
Y
N
P
Findings (responses and comments)
         
Hernias
Testicular masses
Testicular pain
Are you sexually active?
Sexual difficulties
Venereal disease
Discharge or sores
         
Female concerns:
Y
N
P
Findings (responses and comments)
         
Age of first menses
Average number of days
Length of cycle
Bleeding between period
Regularity of cycle
Painful menses
Excessive flow
Scanty flow
PMS (mood changes)
Birth control- type?
Number of pregnancies
Number of live births
Number of miscarriages
Number of abortions
Difficulty conceiving
Are you sexually active?
Pain during intercourse
Sexual difficulties
Venereal disease
Last menstrual period
Vaginal discharge
Vaginal itching
Last PAP
Ceasing of menses
Hot flashes
         
Breasts:
Y
N
P
Findings (responses and comments)
         
Do you do self-exam?
Lumps
Pain/tenderness
Nipple discharge
         
Musculoskeletal:
Y
N
P
Findings (responses and comments)
         
Joint pain or stiffness
Arthritis
Broken bones
Muscle spasms/cramps
Weakness
Joint swelling
Backache
Tight muscles
Muscle twitching
         
Neurologic:
Y
N
P
Findings (responses and comments)
         
Fainting
Seizures/Convulsions
Paralysis
Muscle weakness
Numbness or tingling
Loss of memory
Involuntary movement
Loss of balance
Speech problems
Tremors
Difficulty concentrating
Difficulty initiating movement
         
Endocrine:
Y
N
P
Findings (responses and comments)
         
Heat or cold intolerance
Thyroid disease
Excessive thirst
Excessive hunger
Excessive urination
Excessive sweating
Diabetes
Hypoglycemia
Hormone therapy
Sudden weight gain/loss
         
Blood/Lymphatic:
Y
N
P
Findings (responses and comments)
         
Anemia
Easy bleeding or bruising
Past transfusions
Lymph node swelling
         
Allergic history:
Y
N
P
Findings (responses and comments)
         
Drug sensitivity
Reaction to vaccine
Allergies? Please list:
         
Injuries:
Y
N
P
Findings (responses and comments)
         
Broken bones
Sprains
Whiplash
Lacerations
         
Mental/Emotional:
Y
N
P
Findings (responses and comments)
         
Depression
Mood swings
Anxiety
Nervousness
Tension

Fears/Phobia(s)
please list:
Alcohol/drug abuse
Insomnia
Irritability
Decrease sexual desire
Problems with memory
Problems with concentration
         
Sleep/Dreams:
Y
N
P
Findings (responses and comments)
         
Do you wake rested?
Do you sleep enough?
Early riser
Do you recall dreaming?
Do you have thematic or recurring dreams?
         
Other:
Y
N
P
Findings (responses and comments)
         
Consume 3 meals daily
Enjoy employment
Watch Television
Read books
Take vacations
Treatment for drug dependence
Use of recreational drugs
Use of alcohol
Treatment for alcoholism
What are your main interests/hobbies? Please list:
Do you exercise? how/how often:

 

Anything Else?:

 

 
Vaughan Medical Centre 2009-2010