PEDIATRIC UROLOGY ASSOCIATES, P.C.

 

REVIEW OF SYSTEMS

 

Patient Name:_____________________________   Date of Appt:____________

 

Date of Birth:________________________

 

***Please fill in each circle completely.  Do not use checkmarks or an “X”**

 

Genitourinary - female		Musculoskeletal
Blood in urine	OYes   O  No	Special needs i.e. brace, wheelchair	OYes   O  No
Painful urination	OYes   O  No	Back pain	OYes   O  No
Complains of  pain   in the vagina	OYes   O  No	General
		fever	OYes   O  No
Genitourinary - Male		appetite loss	OYes   O  No
		problems with anesthesia	OYes   O  No
Blood in urine	OYes   O  No	chills	OYes   O  No
Painful urination	OYes   O  No	headaches	OYes   O  No
Testicular pain	OYes   O  No
Psychology		ENT/Respiratory
Depression	OYes   O  No	nose bleeds	OYes   O  No
Sleep disturbances	OYes   O  No	history of asthma
Anxious/worries	OYes   O  No	or reactive airway disease	OYes   O  No
ADD/ADHD	OYes   O  No
Developmental delay	OYes   O  No	Neurology
Obsessive/		Weakness or numbness	OYes   O  No
compulsive behavior	OYes   O  No	Seizure disorder	OYes   O  No
		Spina bifida	OYes   O  No
Cardiology		Ophthalmology
Dizziness	OYes   O  No	Diminished vision	OYes   O  No
Palpitations	OYes   O  No
History of heart murmur	OYes   O  No	Allergic/Immunologic
Heart surgery	OYes   O  No	latex and/or
		other allergies	OYes   O  No
Gastroenterology		lupus	OYes   O  No
Blood in stool	OYes   O  No
Constipation	OYes   O  No	Hematologic/lymphatic
Nausea	OYes   O  No	Swollen gland
Abdominal pain	OYes   O  No	(lymph nodes)	OYes   O  No
		Anemia	OYes   O  No
Dermatology		Unusual bleeding and/
Skin rash	OYes   O  No	or bruising	OYes   O  No
Eczema	OYes   O  No
Endocrinology
Growth Problems	OYes   O  No
Excessive Thirst	OYes   O  No
Weight loss	OYes   O  No
Excessive  weight gain	OYes   O  No