2. REVIEW OF SYSTEMS

 

Constitutional

Symptoms: c No complaint, including no _______________ c Had history of _______________________

c Complained of

 

Eyes: c No complaint, including no ________________________ c Had history of _______________________

c Wearing glasses/contacts for __________________

c Complained of

 

Ears, Nose,

Mouth, Throat: c No complaint, including no _______________ c Had history of _______________________

c Wearing hearing aid on ____ side

c Wearing dentures, lower and upper plates.

c Complained of

 

Respiratory: c No complaint, including no _______________ c Had history of _______________________

c Complained of

 

Cardiovascular: c No complaint, including no _______________ c Had history of _______________________

c Complained of

 

Gastrointestinal: c No complaint, including no _______________ c Had history of _______________________

c Complained of

 

Genitourinary: c No complaint, including no _______________ c Had history of _______________________

c Complained of

 

Musculoskletal: c No complaint, including no _______________ c Had history of ______________________

c Complained of

 

Skin/Breast: c No complaint, including no _______________ c Had history of _______________________

c Complained of

 

Neurologic: c No complaint, including no _______________ c Had history of _______________________

c Complained of

 

Psychiatric: c No complaint, including no _______________ c Had history of _______________________

c Complained of

 

Endocrine: c No complaint, including no _______________ c Had history of _______________________

c Complained of

 

Hematologic/ c No complaint, including no _______________ c Had history of _______________________

Lymphatic: c Complained of

Allergy/ c No complaint, including no _______________ c Had history of _______________________

Immunologic: c Complained of

 

Vccination:

 

Age 11-24: c Td in _______ c Chicken pox in _______ c Hepatitis B in _______

c MMR in _______ c Rubella in _______ c

 

Age 25-64: c Td in _______ c rubella (childbearing age) _______

c Flu at age ≥ 50 in _______ c

≥ 65 years: c Td in _______ c Pneumococcal in ______ c flu in _______

 

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