Adult Health Assessment Form - Pennsylvania
REVIEW OF SYSTEMS
SKIN: RESPIRATORY: MUSCULOSKELETAL:
pigmentation cough fracture
rash persistent cough back pain
scaling persistent sputum arthritis
itching sputum gout
bruising coughing up blood fibromyalgia
lumps or bumps shortness of breath muscular weakness
hair changes wheezing or shortness nocturnal cramping
nail changes of breath with exertion joint pain
psoriasis
CARDIOVASCULAR: NEUROLOGIC:
rosacea palpitations headaches
seborrhea rapid heartbeat migraine headaches
skin malignancy irregular heart beat fainting
recurrent herpes chest pain seizures
EYES: chest pain with exertion paralysis
cataracts shortness of breath at night numbness or tingli ng of hands
visual blurring shortness of breath lying flat numbness or tingli ng of feet
double vision lower extremity edema involuntary movements
glaucoma cyanosis tremor
eye pain calf pain when walking neuropathy
color blindness phlebitis benign positional vertigo
glasses or contacts varicose veins
PSYCHIATRIC:
blind spots
GASTROINTESTINAL: sleep disturbance
dry eye difficulty swallowing anxiety
conjunctivitis dyspepsia difficulty with memory
uveitis vomiting blood nervous breakdown
visual loss abdominal pain depression
blindness excessive gas or bloating sexual difficulties
xanthelasma dark or tarry stools marital problems
EARS/NOSE/THROAT: blood in the stool abusive relationship
deafness constipation excessive alcohol consumption
tinnitus diarrhea illegal drug usage
vertigo jaundice
HEMATOLOGIC/LYMPHATIC/
nose bleeds nausea
IMMUNOLOGIC:
deviated septum vomiting anemia
frequent colds abdominal cramps bleeding disorder
sinus trouble loose or frequent BMs bruising
persistent sore throat
GENITOURINARY: fever
tonsillitis urinating at night night sweats
bleeding gums difficulty with urination chills
dental problem frequency weight loss
sinusitis hesitancy swollen nodes
hoarseness blood in the urine HIV risk factors
incontinence allergies
urgency hay fever
stress incontinence
ENDOCRINE:
urge incontinence goiter
erectile dysfunction thyroid disorder
diabetes
osteoporosis
Name hyperlipidemia
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