REVIEW OF SYSTEMS/PHYSICAL ASSESSMENT

Name:______________________________                                       SS#_______________________________

        HISTORY: (Subjective)  Review of Systems 
 + =  Positive                         --     =  Negative responses
 PHYSICAL EXAM :(Objective)-
Document Findings from Physical Exam)
A. Integument                                                             Comments 

Color changes
Pruritis 
Infections
Inflammations
Tumor
Hair changes
Nail changes
Bruising
Cuts failing to heal
Rashes
Lesions/burns/scars
Moles, changes
Birthmark
-
B. Head/Skull/Scalp/Pace                                         Comments

Headache
Trauma to head or face
Sinus tenderness
Scalp itching/infestation

 -
C.     Eyes                                                                     Comments

Visual acuity
Artificial eye
Cataracts - IOL
Blurring
Diplopia
Strabismus
Discharge
Pain/itching
Inflammation
Excessive tearing
Date of last examination
Glasses/contact lens/(last prescription change)
Ever tested for glaucoma?_____When?_____

 -
D.Ears                                                                                    Comments 

Hearing Loss/Sensitivity
Tinnitus
Discharge
Earache/trauma
Vertigo
Recent infection

 -
E. Mouth and Throat                                                       Comments

Gums
Teeth
Temporal mandibular joint
Age at eruption of teeth
Spacers or bridges
Braces
Number of teeth at one year
Sore tongue
Sore throat
Hoarseness/voice change
Goiter
Difficulty swallowing
Date of last dental exam
Frequency of dental hygiene
Cleft lip or palate

 -
F. Respiratory                                                                      Comments

Cough/frequency
Sputum
Hemoptysis
Wheezing
Dyspnea on exertion (DOE)
Positive tuberculin test
Recurrent respiratory infections
Night Sweats
Recent chest x-ray
 

 -
G. Breast                                                                                     Comments

Performance of SBE/Pregnancy
Absence of breast (s)
Breast implant (s)
Fibrocystic disease
Lymph node enlargement
Nipple retraction
Discharge/tenderness
Breast development
(Preadolescents only)
Concerns about breast development
(Preadolescents males/females
Lumps/tumors

 -
H. Cardiovascular                                               Comments

Chest Pain
Orthopnea
Palpitations
Murmur
Hypertension
Anemia
Edema
Varicosities
Thrombophlebitis
Intermittent claudication
 
-Pulses          R                             L___
Carotid_____________________
Brachial____________________
Radial______________________
Femoral_____________________
Popliteal____________________
Dorsalis pedis________________
Post-tibial___________________
O=absent: 1=diminished:2=expected(norm)3=full4=bounding
I.   Abdominal/Rectal                                         Comments

Pain
Appetite/weight change
Nausea
Flatus
Indigestion
Food intolerance
Diarrhea/constipation
Hemorrhoids
Laxatives;enemas
Hernia
Ostomy
Bowel habits

 -

 
J. Genitourinary/Reproduction                                         Comments

Frequency
Nocturia
Urgency
Dysuria
Incontinence
Flank pain
Sexually transmitted disease
Discharge
Lesions
Hematuria
Pyuria
Infections
Stones
Onset of menarche
Duration
Cycle/days
Regularity
Dysmenorrhea
Leukorrhea
Last pap smear
Gravida/para
Date of menopause
Performance of TSE/Frequency

 -

 

K. Musculoskeletal                                                      Comments

Weakness
Pain
Swelling
Redness
Heat
Stiffness
Limitation of motion
Prosthesis
Paralysis/parents
Coordination
Postural deformities
Changes in gait

 -

 
L.  Neurological                                                            Comments

Headache
Syncope
Convulsions
Vertigo
Tremor
Memory Change
LOC
Speech
Orientation

 Reflexes:                         R                        L
Biceps Triceps 
Brachioradialis 
Patellar 
Achilles 
Plantar 
Abdominal 

0=absent: tr=trace; 1=decreased;2=normal; 3=hyperactive; 4=clonus

Revised July, 2002