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Nephrology Associates of Dayton
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Nephrology Associates of Dayton
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Review of Systems
Review of Systems
Name
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Date
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Date of Birth
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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
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