ros

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1 SOUTHERN INDIANA NEPHROLOGY AND HYPERTENSION, PC Review of Systems page 1 of 2 Name________________________________________ Date ___________ As part of your visit, we would like to get an idea of your overall health. Please circle yes or no for each question listed below. Response General No Yes 1. Have you recently been hospitalized? If so, where? ___________________ when?_____________ 2. Do you have problems with fevers or chills on a regular basis? No Yes 3. Have you recenly been on an antibiotic? Yes No 4. Do you take any over the counter medicines for pain (NSAIDs like Aleve, ibuprophen, Motrin, etc)? No Yes No Yes 5. Have you recently had any kind of test where you got dye or contrast? 6. Have you had any weight loss or gain in the last year? No Yes 7. Have you had any night sweats? No Yes 8. Do you frequently feel weak, tired, or lack energy? No Yes Comments: Head/Eyes/Nose 1. Have you had any recent changes in your vision, hearing, or speech? No Yes 2. Do you have sinus congestion on a regular basis? No Yes 3. Do you get sores in your mouth on a regular basis? No Yes Comments: Heart 1. Do you have chest pain? No Yes 2. Do you wake up in the night feeling short of breath? Yes No 3. Do you sleep on more than 2 pillows or upright in the bed or recliner? Yes No Comments: Lungs 1. Do you feel short of breath at rest? No Yes 2. Do you feel short of breath with activity? Yes No 3. Do you have a cough on a regular basis? Yes No Comments: Stomach/Bowels 1. Have you have any bitter tastes in your mouth recently? Yes No 2. Do you throw-up on a regular basis? Yes No 3. Do you ever see any bright red blood in your stools? Yes No 4. Do you ever have dark, tarry stools? No Yes 5. Do you have diarrhea on a regular basis? Yes No Comments: SOUTHERN INDIANA NEPHROLOGY AND HYPERTENSION, PC

2 Review of Systems page 2 of 2 Kidneys Response 1. Do you ever see any blood in your urine? Yes No 2. Do you have pain or burning when you urinate? Yes No 3. Do you notice any foaminess to your urine? No Yes 4. Have you ever passed any kidney stones? No Yes 5. Do you strain to urinate? No Yes Yes 6. Do you feel like you have fully emptied your bladder when you urinate? No 6. Do you get up in the night to urinate? Yes No Comments: Skin 1. Do you get any rashes or sores on a regular basis? Yes No 2. Do you have any open areas on your skin now? Yes No Comments: Muscles/Bones 1. Do you have any joints that are red, hot, and swollen? No Yes 2. Do you have any joints that hurt on a daily basis? No Yes Comments: Nerves 1. Do you have any numbness or tingling in your feet or hands? No Yes 2. Do you have weakness on one side or the other? Yes No 3. Have you had any problems with seizures? Yes No Comments: Endocrine 1. Do you feel you are always hot? No Yes 2. Do you feel you are always cold? No Yes 3. If you have diabetes, is your blood sugar regularly more than 200? No Yes 4. Do you have trouble sleeping? Yes No No 5. Has your energy level changed? Yes Comments: Blood/Lymph Nodes 1. Do you notice easy bruising? Yes No 2. Have you had any recent bleeding? Yes No 3. Have you noticed any swollen glands recently? Yes No Comments: Patient Signature__________________________________ Date____________ Physician Signature________________________________ Date____________

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