Revised: 10/07/09

Review of Systems
Past, Family, Social History Patient Identification Sticker
Treatment Questionnaire
Page 1 of 2

Today’s Date:
Please indicate if you are currently experiencing any of these symptoms on a persistent or frequently recurring basis.
Ignore the gray column. This will be completed by your healthcare provider.

Addresse
d by Addresse
Provider Ye No d by Ye No
s Provider s
Constitutional Musculoskeletal
poor general health recently joint pain, stiffness or swelling muscle pain,
recent weight change, loss of appetite fever, weakness or cramping limitation of motion,
chills, profuse sweating difficulty walking chronic neck or back pain
fatigue, lethargy, malaise chronic foot pain or deformity
Eyes Skin and Breasts
recent eye disease, injury or surgery blurred chronic or recurring rashes or sores
vision, double vision, loss of vision pain in the suspicious moles or skin lesions hair loss,
eyes change in nails
eye examination within the last year Ears, breast pain, breast lump or nipple discharge
Nose, Mouth, Throat hearing loss or Neurologic
ringing in the ears ear pain or discharge frequent or recurring headaches
chronic or recurring sinus problems dizziness, lightheadedness seizures or
chronic or recurring sores in the nose or mouth convulsions
chronic or recurring dental problems loss of sensation or muscle strength stroke
chronic or recurring sore throat or head injury
Cardiovascular memory loss, confusion
chest pain tremor
rapid or irregular heartbeat, palpitations Psychiatric nervousness or
sudden loss of consciousness, fainting anxiety chronic depression
shortness of breath with exertion swelling of inability to concentrate sleep
the feet, ankles or hands Respiratory problems Endocrine
chronic coughing coughing up excessive thirst or urination heat
blood chronic wheezing, asthma or cold intolerance
chronic shortness of breath unexplained change in skin pigmentation
Gastrointestinal change in hat or ring size
recurring nausea and vomiting, vomiting blood loss of height
abdominal pain unexplained bone fractures
chronic or recurring diarrhea or constipation Hematologic / Lymphatic
bloody bowel movements recurring nosebleeds, bleeding gums, bruising
jaundice, liver disease chronic anemia, recent transfusion
Genitourinary swollen lymph nodes recurring
frequent or painful urination blood infections Allergic /
in the urine Immunologic hay fever
urinary incontinence recurring hives history of
loss of sexual desire or sexual dysfunction HIV or AIDS
irregular or painful menstrual periods

Review of Systems
Past, Family, Social History Patient Identification Sticker
Treatment Questionnaire
Page 2 of 2
 Please help us help you by providing the following information. Patients who do not have diabetes may ignore the Diabetes
Self-Management Questionaire.

Addressed by
Provider Yes No Addresse Yes No
d by
Past Medical History Provider Diabetes Self-Management Questionnaire
diabetes, gestational diabetes, high blood sugar Have you been to the hospital emergency room in
hypertension, high blood pressure the past year specifically because of diabetes?

hyperlipidemia, high cholesterol or triglyceride Have you had a dilated eye examination within the
last year?
cardiovascular (heart or blood vessel) disease
stroke or TIA Do you inspect your feet daily?
thyroid disease
parathyroid disease or high blood calcium Do you follow diabetes foot care guidelines?
pituitary disease
adrenal disease Have you seen a registered dietitian in the last year?
gonadal disease
Family History Do you follow a diabetes meal plan?
diabetes, high blood sugar
hypertension, high blood pressure Are you involved in a regularly scheduled exercise
program?
hyperlipidemia, high cholesterol or triglyceride
cardiovascular (heart or blood vessel) disease Do you monitor your blood glucose daily?
thyroid disease
other hormonal diseases Do you record all blood glucose results in a logbook?
Social History
Do you smoke? Do you follow guidelines for treating hypoglycemia?
How long? yrs. How much? packs.
Do you drink alcohol? Do you follow diabetes sick-day guidelines?
How much? .
Do you use recreational drugs? Have you received an influenza vaccination in the
last year?
Which? .
Do you engage in hazardous activities? Have you received a pneumonia vaccination in the
last 5 years?
What? .

Please make additional comments here:

Patient signature: Practitioner signature:

Date: Date: