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Review of Systems
Review of System Questionnaire
Client name
*
First
Last
Date
*
Date Format: 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
*
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