Carrboro Family Medicine Center

Review of Systems

Name: ______________________________ Physician: ___________________

Date: _______________________________ Chart#: ______________________

Yes No General: (Comments to be completed by provider)

___ ___ Loss of appetite
___ ___ Fatigue
___ ___ Fever
___ ___ Change in weight
___ ___ Do you smoke?
___ ___ if so, do you wish to quit?
___ ___ Do you drink alcohol?
___ ___ if so, over two drinks daily?
___ ___ Follow low cholesterol diet?
___ ___ Exercise
__________ How many hours a week?
___ ___ Date of last Tetanus shot
Skin:
___ ___ Skin problems
___ ___ Unusual or changed moles
Head, eyes, ears, nose, throat:
_________ Date of last dental exam
__________ Date of last eye exam
___ ___ Eye/Vision problems
___ ___ Nasal congestion
___ ___ Runny nose
___ ___ Hearing difficulty
___ ___ Chronic sore throat
Neck:
___ ___ Swollen glands
Respiratory:
___ ___ Chronic cough
___ ___ Shortness of breath
___ ___ Wheezing
Breast:
___ ___ Monthly self breast exam
___ ___ Breast mass
___ ___ Breast pain
___ ___ Nipple discharge
___ ___ Skin changes
Cardiovascular:
___ ___ Chest pain or tightness
___ ___ Edema or swollen ankles
___ ___ Palpitations
___ ___ Wake up suffocating

Please continue on the back of this form.

Yes No Gastrointestinal: (Comments to Be Completed By Provider)
___________ Date of last sigmoid/colonoscopy
___ ___ Abdominal pain
___ ___ Constipation
___ ___ Diarrhea
___ ___ Difficulty Swallowing
___ ___ Frequent Heartburn
___ ___ Hemorrhoids
___ ___ Blood in stool or black stool
___ ___ Nausea or vomiting
Female Genitourinary: Male Genitourinary: Yes No
__________ Date of last menstrual period Painful urination ___ ___
__________ Date of last bone density Pink/red urine ___ ___
__________ Date of last mammogram # urinations at night ___ ___
__________ Date of last PAP Testicular exam ___ ___
___ ___ History of abnormal PAP Monthly testicular exam ___ ___
___ ___ Pain with intercourse Penile discharge ___ ___
___ ___ Painful urination
___ ___ Pink/red urine
___ ___ Incontinence of urine
___ ___ Menstrual problems/irregularity
__________ Form of contraception
___ ___ Vaginal discharge
___ ___ Worried about sexual diseases
Musculoskeletal:
___ ___ Back or neck pain
___ ___ Joint pain
___ ___ Joint swelling
___ ___ Muscle pain
Neurological:
___ ___ Dizziness or fainting
___ ___ Frequent or severe headaches
___ ___ Numbness
___ ___ Weakness in extremities
Psychiatric:
___ ___ Anxiety or Nervousness
___ ___ Depression
___ ___ Insomnia or change in sleep
___ ___ Irritability
Endocrine:
___ ___ Cold intolerance
___ ___ Hair loss
___ ___ Heat intolerance
___ ___ Hot flashes
___ ___ Decreased libido
___ ___ Sexual dysfunction
Hematology:
___ ___ Enlarged lymph nodes

Current meds:
Herbs or Supplements: __________________________________________________________
Seeing any Specialists (indicate name and reason):___________________________________

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