NAME:

MR#:
Ambulatory Services

ADOLESCENT REVIEW OF SYSTEMS BIRTHDATE:

Instructions: Check the box for each symptom that the patient has
had in the past three months. Fill in the blank spaces.

GENERAL G Pain
G Weakness G Stiffness
G Fatigue G Weakness
G Chills G Twitching
G Night sweats G Deformity
G Change in weight, appetite or sleeping habits G Chronic back pain
EYES G Joint swelling
G Glasses or contacts G Decreased range of motion
G Blank spots in your field of vision VAGINAL and URINARY (Female)
G Excessive tearing or discharge G Vaginal itching or burning
G Eye pain G Vaginal discharge
G Double vision G Sexually active
G Last eye exam, Date: ____________________________ G Sexually transmitted diseases (herpes, syphilis, chlamydia,
EARS, NOSE, SINUSES, MOUTH and THROAT gonorrhea, AIDS, etc.)
G Loss or trouble hearing G Age at menarche: _____________________________________
G Ringing G Last menstrual period, Date: ___________________________
G Drainage G Problems with menstrual periods
G Frequent headaches G Last pap smear, Date: _________________________________
G Nosebleed G Methods of contraception: _____________________________
G Post nasal drip G Pregnancies, number:
G Blockage of nose __________________________________
G Sinus pain G Problems during pregnancy
G Sore throat G Miscarriages or abortions, number: _____________________
G Hoarseness G Pain or frequent urination
G Speech problems G Previous urinary tract infections
G Bleeding gums G Blood in urine
G Teeth problems _________________________________ G Kidney stones
G Last dental exam, Date: _________________________ GENITAL and URINARY (Male)
G Orthodontia G Hernia
LUNGS G Discharge from penis
G Cough G Pain or lump in testicles
G Wheezing G Sexually active
G Shortness of breath G Method of contraception: ______________________________
G Spitting up blood G Sexually transmitted diseases (herpes, syphilis, chlamydia,
G Positive TB Test AIDS, etc.)
HEART G Pain or frequent urination
G Chest pain G Previous urinary tract infections
G Palpitations (heart pounding) G Blood in urine
G Trouble breathing at night G Kidney stones
G Fatigue easily with exercise HEMATOLOGIC and LYMPHATIC
G Ankle swelling G Easy bruising or bleeding problems
SKIN G Swollen lymph nodes
G Itching ENDOCRINE
G Rash G Excessively hot
G Change in color G Excessively cold
G Changes in warts, moles, or birthmarks G Always thirsty
G Acne G Always hungry
BREAST NERVOUS SYSTEM
G Lumps in breast G Headaches
G Discharge from nipple G Numbness
GASTROINTESTINAL G Dizziness or passing out
G Vomiting G Loss of coordination or balance
G Difficulty swallowing G Head injury
G Stomach or abdominal pain G Seizures
G Indigestion or heartburn PSYCHOLOGICAL
G Ulcers G Nervousness/anxiety/stress
G Changes in bowel habits G Depression
G Blood in stools (or black stools) G Unable to sleep
G Nightmares
G Rape/partner violence or harassment
3039329 (6/02)
Provider Signature __________________________________ Date
_________
MUSCULOSKELETAL