APPENDIX B

REVIEW OF SYSTEMS (EXHAUSTIVE)

WITH SPECIAL HISTORY AND PHYSICAL SECTIONS
Development of a HPI:

Pain Review An Example of HPI Development:

____ Chief complaint (description of current episode)

____Duration of current episode
____Onset (gradual vs. sudden
____Progression since onset (lessening vs. worsening)
____Precipitating factors
____Exertion
____Trauma/muscle strain
____Emotional stress
____Food intake
____Aggravating/relieving factors
____Activity/exercise
____Position
____Breathing/coughing/sneezing
____Movement
____Touch (tenderness)
____Food intake
____Self Rx
____Physician/other Rx
____Associated symptoms
____Prior similar episodes
____Number of prior episodes
____Frequency of episodes (increasing/decreasing?)
____Severity of episodes changing?
____Durations of episodes changing?
____Precipitating factor(s)
____Exertion
____Emotional stress
____Food Intake
____Exacerbating/relieving factors
____Activity/exertion
____Position
____Breathing/coughing/sneezing
____Movement
____Touch (tenderness)
____Food intake
____Self Rx
____Physician/other Rx
____Associated symptoms
____Prior diagnosis and/or work-up
(who, where, when?)
____Hx related illness and/or surgery
[A review of appropriate systems should be
conducted at this point.]
____Impact of illness on daily
routine/lifestyle/employment
____Patient concerns about illness
____FH similar illness
____Chronic diseases/disabilities
____Current medications
____Medication allergies

____Pain: Location (precise)

____Pain: Episodic vs. chronic
____Pain: Duration of current episode
____Pain: Quality (aching, dull, sharp)
____Pain: Intensity/severity (mild/moderate/severe)
____Pain: Deep vs. superficial
____Pain: Radiations
____Pain: Onset
____Pain: Progression (stable vs. increasing intensity)
____Pain: Precipitating factor(s)?
____Trauma/muscle strain
____Exercise/exertion/activity associations
____Emotional stress
____Food intake
____Pain: Aggravating/relieving factors
____Position
____Movement
____Touch (overlying tenderness)
____Breathing/coughing/sneezing
____Food intake
____Self Rx (medications, etc.)
____Physician Rx
____Pain: Interference with sleep
____Pain: Associated Sx
____Preceding illness/chronic diseases
____Prior similar pain
____First time pain noted
____Number of prior episodes
____Durations of prior episodes
____Prior pain like/unlike
present episode (how different?)
____Episodes increasing/decreasing
in frequency?
____Precipitating factors for prior episodes
____Exertion/activity associations
____Food intake
____Emotional Stress
____Aggravating/relieving factors
____Position
____Movement
____Touch (overlying tenderness)
____Breathing/coughing/sneezing
____Food intake
____Self Rx (medications, etc.)
____Physician Rx
____Related to prior illness(es) or surgeries
____Psychosocial stressors
[Appropriate ROS data should be included at this point: e.g. for
chest pain-CV, pulm, GI, MS and psych ROS data may all be
relevant here.]
____Impact of pain on lifestyle/daily routine
____Patient concerns about pain
____FH similar problems/pain
____Current meds
____Chronic diseases
____Medication allergies

Occupational/Activity History

Infectious Disease Review (cont)

____Occupation
____Hobbies/recreational activities
____Household chores/duties

____Changes in Urination
____Dysuria
____Frequency/nocturia
____Urgency
____Void volume changes
____Back/flank pain
____Hx recurrent UTIs and/or UT
abnormalities/surgeries
____Reproductive tract problems
____Discharge
____Lesions
____Hx VD/RT infections
____Number and sex of present & past
sex partners
____Partners with HIV/AIDS or HIV risk factors
____Dyspareunia (women)
____Abdominal pain/tenderness
____LMP
____Tampon use +/____Contraception (esp. IUD)

Exposures:
____Asbestos
____Dust (silicates, coal, plaster, insulation)
____Solvents/chemicals (inc. vapors)
____Noise
____Heavy metals (e.g. lead: paint, plumbing;
arsenic: treated lumber)
____Toxins/caustics (e.g. pesticides, herbicides,
Rodenticides)
____Medications (e.g. in anesthesia and
chemotherapy nurses)
Physical activities:
____Sports/hobby-related
____Occupational

Infectious Disease Review:

General

____Contact with ill individuals (children, spouse,

friends, occupational)
____Recent travel (esp. foreign)
____Outdoor activities
____Insect exposure (ticks, spiders, mosquitoes)
____Unpurified water consumption (giardiasis)
____Animal exposures
____Pets (inc. ill pets)
____Farm animals
____Endemic animals (birds, rats, mice, skunks,
squirrels, bats, other wild)
____Carcasses (e.g. from hunting, taxidermy)
____TB contact
____Last TB skin test
____Last CXR
____Immunizations (inc. flu, pneumovax,
hepatitis B, rubella, tetanus)
____Recent and/or recurrent infection Hx
____Immunological deficiency Hx (heritable,
2 CA/HIV)
____Medications (esp. steroids, immunosuppressive, CA meds, antimicrobials)
____Rash/skin changes
____Lymphadenopathy
____Weight loss
____Night sweats/fever/chills/rigors
____Respiratory Sx
____Sore throat
____Runny nose
____Ear congestion
____Cough
____Sputum +/- and color
esp. yellow/green)
____Hemoptysis
____Dyspnea (resting, exertional)
____Chest pain (esp. pleuritic)
____CNS Symptoms
____Headache
____Stiff neck
____Impaired mentation/consciousness
____Seizure
____Heart Problems
____Rheumatic/valvular heart disease (murmur) Hx

____Age
____Height/weight
____Occupation
____General health
____Febrile
____Night sweats
____Appetite
____General mood
____Chronic diseases
____Disabilities/impairments
____Medications (OTC and prescription)
____Medication allergies
____Weight changes (esp. recent)
____Prior health care

Skin/Hair/Nails
____Urticaria
____Rashes
____Lesions (eruptions, abscesses, ulcers)
____Dry Skin
____Pruritus
____Skin color changes
____Pallor
____Cyanosis
____Hyperpigmentation
____Hx of biopsy
____Hx dermatological disease
____Eczema
____Psoriasis
____Acne
____Nail color changes
____Brittle nails
____Nail hemorrhages
____Clubbing
____Change in hair distribution
____Alopecia
____Hirsutism
____Brittle/dry hair
____Hair texture (esp. changes)

HEET/Neck:
____Head/Neck problems
____Lumps/bumps/lymphadenopathy
____Headaches
____location
____duration
____how relieved
____Stiff neck
____Neck pain
____Sinus problems
____Jaw discomfort (TMJ)
____Thyroid problems
____Syncope
____Vertigo
____Injury
____Eye problems
____Diplopia
____Blurring
____Blindness/vision loss
____Color blindness
____Cataracts +/____Glaucoma +/____Last glaucoma test
____Impaired visual fields/peripheral vision
____Flashing light/stars
____Floaters
____Eye Fatigue
____Pain
____Photophobia
____Conjunctivitis
____Inflammation
____Dysfunctional tearing
____Pruritus
____Blepharospasm
____Nystagmus
____Corrective lenses +/- (inc. contacts)
____myopia
____hyperopia
____Scotomata
____Last eye exam
____Ear problems
____Hearing impairment
____Noise exposures
____Balance/equilibrium problems
____Tinnitus
____Congestion
____Pain
____Drainage
____Infection
____Mastoiditis
____Nose problems
____Olfaction/Anosmia
____Obstruction
____Sinusitis
____Congestion
____Rhinorrhea
____Epistaxis
____Deviated septum
____Seasonal problems
____Mouth and Throat Problems
____Teeth problems
____Malocclusion
____Dentures +/____Toothaches
____Last dental exam
____Mouth/tongue lesions
____Gingivitis/bleeding gums

____Pain (inc. cold sores)

____Sore throat
____Tonsillitis (tonsils +/-)
____Post-nasal drip
____Voice changes/hoarseness/laryngitis

Respiratory:
____Dyspnea
____Resting
____Exertional
____Orthopnea
____PND
____Cough
____Productive +/____Sputum color
____Hemoptysis
____Yellow/green sputum
____Sputum quality
____Sputum (foul odor?)
____Chest pain (esp. pleuritic cyanosis/pallor)
____Cyanosis/pallor
____URI Sx (other)
____Sore throat
____Rhinorrhea/nasal congestion
____Ear congestion
____Hx pulmonary disease
____COPD
____Asthma
____Recurrent pulmonary infections/pneumonia
____Cystic fibrosis
____Hx TB/TB exposure
____Occupational pulmonary exposures
____Smoking Hx

Cardiovascular:
____Chest pain (esp. exertional, see pain section below)
____Dyspnea
____Resting
____Exertional
____Orthopnea
____PND
____Nocturia/urinary frequency
____Edema (esp. leg/foot)
____Palpitations/irregular heartbeat
____Tachycardia/bradycardia
____Fainting/dizziness/syncope
____Postural hypotension
____Claudication
____Varicosities
____Raynaud Sx
____Hx CV diseases
____MI/angina
____HTN
____CHF
____Rheumatic/valvular disease (murmurs)
____Arrhythmias
____Hx pulmonary emboli/DVTs
____Hypercholesterolemia
____Postmenopausal +/____Hx diabetes
____Hx smoking

Gastrointestinal:

Reproductive:

____Appetite
____weight loss
____Mouth lesions
____Dysphagia
____Sour mouth taste
____Pyrosis
____Antacid use +/____Nausea/emesis
____Hematemesis
____Dysgusia
____Jaundice
____Dark urine
____Abdominal pain (esp. associated with
eating, see pain section below)
____Flatulence
____Eructation
____Stool changes
____Color
____Red
____Black/tarry
____Grey/tan/pale
____Odor (esp. foul)
____Consistency (soft/loose/hard)
____Frequency (diarrhea/constipation)
____Stool incontinence
____Stool guaiac +/- (hen, results?)
____Proctoscopy/barium enema +/____Hx GI disease
____PUD
____Reflux esophagitis
____Diverticulosis/itis
____Inflammatory bowel disease
____Irritable bowel syndrome
____Colon polyps/CA
____Liver disease (esp. cirrhosis,
hepatitis, biliary tract)
____Cholecystitis
____Pancreatitis
____Hemorrhoids
____Hx prior abdominal surgery
____Hx hernias
____Coffee intake
____Alcohol intake
____Aspirin NSAID intake
____Hx smoking

____Sexually active +/____Frequency of intercourse

____Number and sex(es) of partners
____VD/HIV/AIDS in partners?
____Sexual dysfunction
____Impotence
____Dyspareunia
____Vaginismus
____Decrease libido
____Abdominal pain (esp. during intercourse
or menstruation, see pain section)
____Genital lesions
____Discharge
____Odor
____Bloody?
____Pruritus
____Menstrual Hx
____Age of menarche
____Age at menopause
____Post menopausal Sx +/____LMP
____Duration of bleeding
____Pattern/severity of bleeding
____Frequency and regularity of periods
____Spotting
____Premenstrual syndrome
____Tampons +/____Contraception
____Pregnant?
____Gravida x?
____Para x?
____Abortions x?
____Last PAP
____Testicular problems
____Pain
____Lumps/enlargement
____Injury
____Hernia
____Hx VD
____Chlamydia
____GC
____Syphilis
____HIV +/- AIDS
____Hx reproductive disorders?
____Inability to conceive
____PID
____Ectopic pregnancy
____RT surgery +/- (e.g. hysterectomy,
vasectomy)
____Breast problems?
____Routine self exams +/____Lumps
____Pain/tenderness
____Discharge
____Retraction of nipple
____Dimpling of skin

Nutritional/Diet Survey:
____Special diet +/- (e.g. ovo/lactam
vegetarian, low sodium, low cholesterol;
incl. rational, e.g. Kosher, Hx diabetes)
____Number of meals consumed daily (inc. times
meals taken)
____Preparation of consumed meals (e.g. self at
home, McDonalds, meals on wheels)
____Typical meals (inc. concrete examples)
____Between meal eating
____Beverages (inc. soft drinks, coffee, alcohol)
____Dietary supplements (inc. vitamins, health
food preparations)
____Dieting?

Urological:

Hematologic/Lymphatic:

____Urination problems
____Dysuria
____Hematuria/urine color change
____Pyuria
____Void-volume changes
____Frequency changes
____Dribbling
____Hesitancy
____Incontinence
____Enuresis
____Oliguria
____Hx Ut disease/anomalies
____UT infection (esp. recurrent)
____Renal failure
____Stones
____Prostate problems

____Bleeding problems (inc. hemophilia

____Hemoptysis
____Bruising
____Slow clotting (inc. hemophilia)
____Hematuria
____Heavy periods/abnormal vaginal bleeding
____Melena
____Hematochezia
____Anemia (inc. sickle cell, thalassemia)
____Prior blood transfusions (and rxns)
____Lymphadenopathy (inc. cervical, inguinal, axillary)
____Impaired wound healing
____Recurrent infections +/____Weight loss
____Hx immunosuppression
____HIV/AIDS
____Hx CA

Endocrine/Metabolic:
____Weight loss/gain
____Heat/cold/intolerance
____Weakness/fatigue
____Diaphoresis
____Hyperphagia
____Nervousness/irritability
____Palpitations/tachycardia
____Hypertension
____ Sleep changes
____Polyuria
____Nocturia
____Change in urinary frequency +/____Excessive thirst
____Vision changes
____Visual fields/peripheral vision
____Changes in skin pigmentation +/____Changes in bowel movements
____Changes in hair and hair distribution
____Galactorrhea
____Gynecomastia
____Menstrual changes
____LMP
____Duration of bleeding
____Pattern/severity of bleeding
____Frequency and regularity of
____Spotting
____Premenstrual syndrome
____Pregnant?
____Gravida x?
____Para x?
____Abortions x?
____Fertility known?
____Impotence
____Libido

Musculoskeletal:
____Bone/joint problems
____Pain (inc. backache)
____Inflammation/swelling
____Calor/warmth
____Erythema/redness
____Tenderness
____Limitation of movement
____Stiffness
____Daily fluctuation
____Crepitus
____Interference with daily activities
____Hx bone disease
____Fractures/deformations
____Dislocations
____Arthritis
____Osteoporosis
____Gout
____Muscle/other rheumatologic problems
____Myalgias
____Tenderness
____Weakness
____Atrophy
____Fasciculations
____Cramping
____Raynaud s phenomenon
____Malar/other rash
____Hx muscle disease
____Muscular dystrophy
____Collagen vascular/rheumatologic

Neurological:
____Headaches
____Dizziness/vertigo
____Fainting/LOC
____Seizures
____Tremor/movement disorder
____Tic
____Memory impairment
____Impaired cognition
____Motor impairment (inc. gait)
____Paresis
____Paralysis
____Impaired speech/dysphasia, aphasia
____Sensory impairment (numbness/tingling)
____Paresthesia
____Hyperesthesia
____Hypesthesia
____Coordination impairment
____Ataxia
____Apraxia
____Vision problems +/____Visual fields
____Amaurosis fugax
____Hx neuro problems
____CVA/TIA
____Parkinson s
____Seizure disorder
____Dementia
____CP
____MS
____Trauma

Psychological/psychiatric:
____Depression
____Duration
____Elation (alternating w/depression)
____Weight change
____Appetite change
____Sleep change
____Loss of interest
____Libido changes
____Moodiness
____Hallucinations (inc. auditory, visual, gustatory,
olfactory, tactile)
____Delusions (inc. persecutory)
____Anxiety/nervousness
____Agoraphobia
____Substance abuse (inc. drugs, alcohol,
prescription meds)
____Anorexia nervosa-binge/purge
____Suicidal/homicidal ideation
____Psychosocial stressors
____Family life/romantic life
____Financial
____Employment
____Peers/social life
____Schools
____Hx being abused
____Hx psychiatric disorders
____Depression
____Bipolar
____Psychosis
____Substance abuse
____Anxiety
____Eating disorder (anorexia-binge/purge)