Review of System Questionnaire Client name* First Last Date of Birth* MM slash DD slash YYYY Date* MM slash DD slash YYYY Since the last appointment, has there been any:Please answer the following questions before your child sees the medical provider.1. Weight gain or loss* Yes No 2. Sudden cold or sore throat* Yes No 3. Shortness of breath* Yes No 4. Racing heart or changes in heartbeat* Yes No 5. Appetite change or eating problems* Yes No 6. Constipation/diarrhea* Yes No 7. Nausea/vomiting* Yes No 8. Abnormal posture, movements or gait* Yes No 9. Allergic reactions or rashes* Yes No 10. Yellowing of eyes, skin, or mouth* Yes No 11. Unusual bleeding or bruising* Yes No 12. Headache* Yes No 13. Fainting or dizziness* Yes No 14. Tremor/shaking* Yes No 15. Nicotine/Tobacco use* Yes No 16. Abuse of prescription medication or use of alcohol/illicit drugs (ie. cocaine, marijuana)* Yes No 17. Caffeine (eg: soda, coffee, tea, energy drinks)* Yes No 18. New medications, vitamins, or supplements (to include hormonal supplements)* Yes No 19. New health problems or updates (early physical, sports injury, illness)* Yes No 20. Changes in home environment (separation/divorce, DCF involvement, move)* Yes No 21. Changes in school environment (separation/divorce, DCF involvement, move)* Yes No 22. Changes in social environment (504/IEP update, suspension, new school)* Yes No 23. Any other problems you would like to discuss?* Yes No Other problems*
