Review of Systems -- FSRG 08
INSTRUCTIONS: The following is a list of different problems, activities, safety precautions, and treatments some people may have experienced. Please mark which apply to you, as CURRENT, PAST, FAMILY, or give a NUMBER (Example: 3 meals eaten per day), as appropriate.
Patient Name: *
Your answer
Date of Birth: *
Your answer
Gender: *
Your answer
GENERAL
Unexplained Weight Loss or Gain: *
Required
Weakness / Fatigue: *
Required
Exercise Regularly: *
Required
Persistent Pain: *
Required
Fever / Chills *
Required
Recent Significant Life Changes: *
Required
Financial Hardships: *
Required
Exposure to Pollutants / Toxins *
Required
Sweats / Hot Flashes: *
Required
Difficulty Staying Awake: *
Required
Smoke Detector / Fire Extinguisher in Home: *
Required
Difficulty Sleeping: *
Required
Family, School, or Work Violence or Concerns: *
Required
Number of Meals Daily: *
Your answer
Number of People In Household: *
Your answer
Number of Snacks Daily: *
Your answer
Number of Meals Eaten Out Weekly: *
Your answer
Regular Helmet Use: *
Required
Regular Seatbelt Use: *
Required
Ride a Motorcycle: *
Required
Ride a Bicycle: *
Required
Ride Horses: *
Required
Ski / Snowboard: *
Required
Skateboard: *
Required
Ride an All-Terrain Vehicle: *
Required
Play Contact Sports: *
Required
Exposure to Foreign Countries: *
Required
Skin Sensitivity to Sunlight: *
Required
SKIN
Itching: *
Required
Changes in Hair or Nails: *
Required
New or Changed Moles, Warts, Dimples: *
Required
Acne: *
Required
Easy Bruising: *
Required
Rashes: *
Required
Non-Healing Wounds / Slow Healing / Bad Scars: *
Required
Eczema, Atopic Dermititis, or Psoriasis: *
Required
Dry Skin: *
Required
Changes in Skin Colour: *
Required
Lumps: *
Required
Other: *
Your answer
HEAD
Head / Face / Jaw Injury: *
Required
Deformities: *
Required
Headache: *
Required
Other: *
Your answer
EYES
Use of Glasses or Contact Lenses: *
Required
Eye Pain or Discomfort: *
Required
Double or Blurred Vision: *
Required
Excessive Tearing: *
Required
Eye Redness: *
Required
Seeing Spots or Specks: *
Required
Vision less than 20/40: *
Required
Blind Spots: *
Required
Sensitivity to Light: *
Required
Vision Loss or Low Vision: *
Required
Drooping Eyelids: *
Required
Cataracts *
Required
Glaucoma ('high pressure') *
Required
Flashing Lights: *
Required
Colour Blindness: *
Required
Macular Degeneration: *
Required
Other: *
Required
EARS
Hearing Impairment: *
Required
Tinnitus: *
Required
Perforated Drum: *
Required
Swimmer's Ear / External Ear Infection: *
Required
Middle Ear Infection: *
Required
Discharge: *
Required
Hearing Aids / Hearing Implants: *
Required
Other: *
Your answer
NOSE / SINUSES
Nasal Stuffiness: *
Required
Frequent Colds: *
Required
Medication Allergies: *
Required
Food Allergies: *
Required
Indoor or Outdoor Allergies / Hay Fever: *
Required
Nasal Discharge or Itching: *
Required
Post Nasal Drip: *
Required
Snoring: *
Required
Sleep Apnoea: *
Required
Head Congestion, with Face Pain: *
Required
Nosebleeds: *
Required
Sinus Trouble: *
Required
Nasal Polyps: *
Required
Deviated Nasal Septum: *
Required
Breathing Through the Mouth, not the Nose: *
Required
Other: *
Your answer
NECK
Swollen Glands: *
Required
Goitre: *
Required
Lumps: *
Required
Pain or Stiffness: *
Required
Other: *
Your answer
THROAT / MOUTH
Hoarseness: *
Required
Teeth or Gum Problems: *
Required
Dentures: *
Required
Brush / Floss Teeth Regularly: *
Required
Sore Tongue: *
Required
Problems Swallowing: *
Required
Dry Mouth: *
Required
Frequent Sore Throats: *
Required
Other: *
Your answer
RESPIRATORY
Wheezing: *
Required
Pleurisy: *
Required
Bronchiectasis: *
Required
Tuberculosis or Exposure: *
Required
Emphysema or Chronic Bronchitis: *
Required
Interstitial Lung Disease: *
Required
Tobacco Use or Exposure (Second or Third Hand): *
Required
Reactive Airways Disease / Exercise-Induced Asthma: *
Required
Pheumothorax: *
Required
Pneumonia / Bronchitis: *
Required
Short Breaths: *
Required
Fast Breathing: *
Required
Chronic Obstructive Pulmonary Disease: *
Required
Non-Productive Cough: *
Required
Coughing up Blood / Phlegm: *
Required
Shortness of Breath: *
Required
Other: *
Your answer
CARDIOVASCULAR
Heart Trouble: *
Required
Leg Pain / Cramps: *
Required
Fast or Slow Heartbeat: *
Required
Rheumatic Fever / Heart Disease: *
Required
Irregular Heart Beat: *
Required
Heart Murmurs / Congenital Heart Defect: *
Required
Chest Pain or Discomfort / Pressure in Chest: *
Required
Palpitations / Sensation of Heart Beating: *
Required
Oedema / Swelling / Glove or Shoe Size Change: *
Required
Shortness of Breath While Lying Flat: *
Required
Poor Circulation / Past Clots in the Veins: *
Required
Vascular Surgery: *
Required
Cardiac Catheterisation (‘Heart Cath’): *
Required
Coronary Artery Bypass: *