Review of System Questionnaire

Client name*

First Last

Date of Birth*

Date*

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

Forms – Review of Systems

Review of System Questionnaire

Since the last appointment, has there been any: