Review of Systems - Nephrology Associates of Dayton

Name*

Date*

Date of Birth*

GENERAL

Weight Change

Appetite Change

Fever

Chills

Night Sweats

Fatigue

SKIN

Rash / Sores

Itching

Yellow Jaundice

Change in Hair / Nails

EYES

Blurred Vision

Double Vision

Light Sensitivity

Blindness

Glasses

EARS

Ear Infection

Ringing in Ears

Hearing Loss

NOSE

Sinus

Nosebleeds

Hayfever / Allergies

MOUTH

Bleeding Gums

Frequent Sore Throats

Trouble Swallowing

Hoarseness

NECK

Stiffness

Pain

Lumps

RESPIRATORY

Wheezing

Chronic Cough / Sputum

Coughing Up Blood

CARDIOVASCULAR

Heart Murmur

Shortness of Breath

Shortness of Breath while Lying Flat in Bed

Shortness of Breath while At Rest in a Chair

Shortness of Breath With Activity

Smothering When Asleep

Chest Pain / Heart Attack

Palpitations / Skipped Beat

Leg Pain When Walking

Leg / Abdominal Swelling

GASTROINTESTINAL

Nausea / Vomiting

Diarrhea

Constipation

Vomit Blood

Blood in Stool

Abdominal Pain

GENITOURINARY

Pain / Burning with Urination

Increased Urgency

Urination at Night

Problems Initiating Stream

Problems Stopping Stream

Urgency

Incontinence

Blood in Urine

Foamy Urine

MUSCULOSKELETAL

Muscle Pain

Joint Pain / Arthritis

ENDOCRINE

Increased Thirst

Increased Urination

Increased Appetite

Temperature Intolerance

NEUROPSYCHIATRIC

Seizures

Paralysis

Numbness / Tingling

Depression / Anxiety

HEMATOLOGIC

Low Blood Count

Easy Bruising

Excessive Bleeding

Blood Transfustions