Review of Systems
The purposes of this section are to:
1. Evaluate past and present health of each system
2. Double check if any significant data was missed
3. Evaluate health promotion practices
Although medical terms are used, use terms patients can understand when questioning
the patient. Record the presence of symptoms with a check mark. History is limited to
subjective data, so do not record objective findings here.
N/A = Negative findings
General Overall Health: Weight gain Weight loss Fatigue Weakness
Fever Chills N/A
Skin: Pigment/Color Change Change in Mole Pruritus Bruising
Rash Lesion Excessive Dryness Excessive Moisture
Other Describe: _________________ N/A
Hair/Nails: Recent hair loss Change in texture Change in shape of nails
Brittleness No Change
Health promotion: Amount of sun exposure __________________________________
Head: Frequent/Severe Headaches Head Injury Dizziness
Syncope (fainting) N/A
Eyes: Vision Difficulty Blurring Blind spots Eye pain Diplopia
Redness Swelling Watering Discharge Glaucoma Cataracts N/A
Health Promotion: Eye glasses Contacts Last vision check _______________
Ears: Earaches Hearing loss Infections Drainage
Tinnitus (ringing/buzzing in ears) Vertigo (dizziness/spinning) N/A
Health Promotion: Frequent exposure to loud noise Hearing aid
Method of cleaning ears __________________________________________________
Nose & Sinuses: Discharge Frequent colds Sinus pain Nose bleeds
Allergies Hay fever Change in sense of smell N/A
Mouth & Throat: Mouth Pain Frequent sore throat Bleeding gums
Toothache Lesions Dysphagia Hoarseness Change in voice
Altered taste Dentures N/A
Health Promotion: Daily Dental Care __________________ Last checkup _________
Neck: Pain Stiffness Lumps/ Swelling Tender/Enlarged nodes
Goiter N/A
Breast: Pain Lump Nipple discharge Rash Breast disease
Surgery N/A
Axilla: Lump Rash Tenderness N/A
Health Promotion: Breast Self-Exam date _________________________
Mammogram date _____________
Respiratory System: Asthma Emphysema Bronchitis Tuberculosis
Painful breathing Wheezing Dyspnea Dyspnea with activity Cough
Increased Sputum Hemoptysis Snoring N/A
Health Promotion: Last Pneumonia Vaccination _____________________________
Last Influenza Vaccination ________________________________________________
Cardiovascular System: Chest pain Palpitation Cyanosis
Dyspnea on exertion Orthopnea Paroxysmal nocturnal dyspnea
Edema Heart murmur Hypertension Coronary artery disease
Anemia Pacemaker N/A
Health Promotion: Date of last EKG or Cardiac Tests __________________________
Peripheral Vascular System: (Hands/feet/legs) Coldness Numbness
Tingling Swelling Discoloration in hands/feet Varicose veins
Intermittent Claudication Ulcers N/A
Gastrointestinal System: Dysphagia Heartburn Indigestion
Abdominal Pain Nausea Vomiting Hematemesis
Gallbladder disease Colitis Liver Disease Flatulence Constipation
Diarrhea Change in stool characteristics Black Stools Rectal Bleeding
Hemorrhoids Hernia N/A
Health Promotion: Use of Laxatives _______________
Colonoscopy date _____________
Hematologic System: Bleeding Tendency Excessive bruising
Swollen lymph nodes N/A
Musculoskeletal System: Arthritis Gout Joint pain Joint Stiffness
Joint Swelling Deformity Limitation of movement Muscle Pain
Muscle Weakness Leg cramps Problems with Gait Back Pain
Disc Disease N/A
Neurological System: Seizure Stroke Fainting Blackouts
Weakness Tremors Tics Paralysis Coordination problems
Numbness Tingling Memory problems Nervousness/anxiety
Mood change Depression Hallucination Mental health problem Insomnia
N/A
Urinary System: Frequency Urgency Nocturia Dysuria Polyuria
Oliguria Hesitancy or straining Incontinence Kidney Stones
Urinary tract infections Enlarged prostate Renal disease
Pain in flank or groin N/A
Male Genital System: Penile/testicular pain Sores or lesions
Penile discharge Lumps N/A
Health Promotion: Last testicular and penile exam _______________
Immunizations: HPV _____________________________________
Female Genital System: Age at menarche _______ Last period __________________
Duration/Cycle _____________
Amenorrhea Menorrhagia Premenstrual pain Dysmenorrhea
Pelvic Prolapse Irregular bleeding Vulvar-vaginal itching
Vaginal discharge Menopause _____________ N/A
Health Promotion: Last gynecological exam ____________ Last Pap Test _________
Immunizations: HPV _____________________________________________________
Sexual Health: Sexually Active Dyspareunia [painful intercourse] (female)
STD Erectile Dysfunction (male) Contraceptive Use _____________________
N/A
Home Devices: Cane Wheelchair Walker Crutches Splint/Brace
Feeding Device Artificial Airway Home Oxygen Home Ventilator
CPAP Nebulizer Treatments Trapeze Glasses/Lenses
Bedside Commode Guide/Support Animal Shower Chair Motorized Scooter
Prosthesis N/A
Problem List: Identify three health problems/needs, actual or potential, based on
the findings of the nursing health history.
1.
2.
3.
