Your Name:

Date:

Review of Systems

General

Are you usually tired or worn out?

MorningYes No 

EveningYes No 

Poor Appetite?Yes No 

Always or frequently thirsty?Yes No 

Special diet?Yes No 

Recent weight gain or loss?Yes No 

Usually feel colder than others?Yes No 

Usually feel warmer than others?Yes No 

Perspire easily with exercise?Yes No 

Night sweats?Yes No 

Difficulty sleeping?Yes No 

Falling asleep?Yes No 

Waking up?Yes No 

Skin

Itching?Yes No 

Rashes?Yes No 

Dry skin?Yes No 

Sores?Yes No 

Other:Yes No 

Eyes

Poor Vision?Yes No 

Glaucoma?Yes No 

Dry eyes?Yes No 

Tearing?Yes No 

ENT

Hearing loss?Yes No 

Ringing?Yes No 

Chronic nasal congestion?Yes No 

Constant dry throat?Yes No 

Recurrent sore on lips, tongue, cheeks?Yes No 

Do you grind your teeth?Yes No 

TMJ?Yes No 

Respiratory

Asthma?Yes No 

Emphysema?Yes No 

Constant cough?Yes No 

Blood?Yes No 

Shortness of breath?Yes No 

Smoke?Yes No 

Cardiovascular

High blood pressure?Yes No 

Palpitations?Yes No 

Chest pain?Yes No 

Leg cramps?Yes No 

Varicose veins?Yes No 

Headaches?Yes No 

Musculoskeletal

Structural misalignments?Yes No 

Neck pain?Yes No 

Stiffness?Yes No 

Shoulder pain?Yes No 

Stiffness?Yes No 

Back pain?Yes No 

Joint pain?Yes No 

Stiffness?Yes No 

what brings on pain? (weather, cold, exercise, etc)

What relieves pain?

Gastrointestinal

Bad taste in mouth?Yes No 

Trouble swallowing?Yes No 

Indigestion, heartburn?Yes No 

Loss of appetite?Yes No 

Abdominal pain?Yes No 

Bloated after meals?Yes No 

Diarrhea?Yes No 

Constipation?Yes No 

Black stools?Yes No 

Rectal pain?Yes No 

Burning?Yes No 

Bowel Movements

Daily?Yes No 

Other:

Formed?Yes No 

Soft?Yes No 

Hard?Yes No 

Urine Quantity

More than 5X a day?Yes No 

Less than 5X a day?Yes No 

Urine Color

Pale?Yes No 

Dark?Yes No 

Emotional

Feel blue?Yes No 

Tired?Yes No 

Angry?Yes No 

Shouting?Yes No 

Moody?Yes No 

Afraid?Yes No 

Generally happy at work?Yes No 

Generally happy at home?Yes No 

Stress?Yes No 

Women

Irregular periods?Yes No 

Heavy?Yes No 

PMS?Yes No 

Menopause?Yes No 

Pregnant?Yes No 

Men

Prostate problems?Yes No 

Itching?Yes No 

Pain?Yes No 

Vasectomy?Yes No 

Other?