Review of Symptoms Questionnaire
Patient Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
General
Rows
Yes
No
Good health
Recent weight change
Fever
Fatigue
Headaches
Eyes
Rows
Yes
No
Eye disease/injury
Need glasses/contacts
Blurred/double vision
Glaucoma/cataracts
Ears, Nose, Mouth, Throat
Rows
Yes
No
Hearing loss
Pain/drainage
Sinus problems
Nose bleeds
Mouth sores
Change in voice
Problems Swallowing
Cardiovascular
Rows
Yes
No
Heart Trouble
Chest Pain
Palpitations
Syncope
Swelling limbs
Pulmonary
Rows
Yes
No
Lung disease
Shortness of breath
Unable to lie flat in bed
Night headaches
Chronic cough
Gastrointestinal
Rows
Yes
No
Stomach problems
Poor appetite
Nausea/vomiting
Constipation
Diarrhea
Abdominal pain
Rectal bleeding
Genitourinary
Rows
Yes
No
Frequent urination
Incontinence
Retention
Kidney stones
Sexual difficulties
Menstrual symptoms
Musculoskeletal
Rows
Yes
No
Joint pain
Joint swelling
Neck/back pain
Pain radiating to arms/legs
Muscle cramps
Neurologic/Neuromuscular
Rows
Yes
No
Headaches
Seizures/convulsions
Memory/mentation problems
Stroke/paralysis
Head injury
Weakness/numbness
Tremors/movement disorder
Insomnia
Psychiatric
Rows
Yes
No
Anxiety
Depression
Psychosis
Endocrine
Rows
Yes
No
Thyroid problems
Diabetes mellitus
Excessive thirst
Cold intolerance
Integumentary
Rows
Yes
No
Skin disease
Skin cancer
Rash/itching
Change in hair/nails
Varicose veins
Breast disease
Submit
Should be Empty: