Cincinnati Podiatrist | Center for Foot Care | Dr. Kristin ...
Dr. Kristin K. Titko
513-729-4455
CHECKLIST: Review of Systems
|General- | Cardiovascular- |Endocrine- |
|Weight loss |Cold feet | |
| | | |
| | | |
| | | |
| | | |
| Weight gain |Night cramps |Sweating |
| | | |
|Fatigue |Intermittent claudication |Frequent urination |
|Fever or chills |Swelling of feet/ankles |Thirst |
|Weakness |Heart disease |Change in appetite |
|Loss of Appetite | |Diabetes |
| |Gastrointestinal- |If yes - Type 1 or Type 2 |
|Skin- |Indigestion (Dyspepsia) | |
| |Ulcers | |
|Itching (pruritis) |Diarrhea | Surgical Concerns- |
|Dryness |GI bleeding |Anesthesia problems |
| | | |
|Open wounds |Liver disease |Wound healing |
|Nail changes/fungus | | problems |
|Rashes | Vascular- | |
| |Calf Pain with walking | Please check if you are |
|Respiratory- |Leg cramping | being treated for any |
| | | |
|Shortness of breath | | of the following: |
| | | |
|COPD | Psychiatric- |Thyroid |
|Painful breathing |Nervousness |Osteopenia |
|Asthma |Stress |Drug abuse |
|Cough |Depression |COPD |
| |Memory loss |AIDS/HIV |
|Musculoskeletal-Joint/muscle stiffness | |Hepatitis |
|Joint/muscle stiffness | Neurologic- |Alcoholism |
|Back pain |burning in feet/legs |Alzheimer’s |
|Redness of joints |Seizures |Blood Clots where? |
|Swelling of joints |Unsteady gait |Cancer where? |
|Osteoarthritis |Tremors |High Cholesterol |
|Gout |Dizziness |Diabetes |
|Rheumatoid Arthritis |Fainting | High Blood Pressure |
|Muscle or joint pain |Tingling in feet/legs | CVA/Stroke |
| |Numbness in feet/legs feet/ankles | ⎕ Kidney Disease |
|Hematologic- |Weakness in feet/legs | ⎕Take Blood Thinner |
| | | |
|Ease of bleeding | | Current weight?__________ |
|List Other Medical Conditions: | | |
| | |Current height?___________ |
| | | |
|Ease of bruising | | |
I do not have any of the above conditions
Patient’s Name: ____________________________
Patient Signature:___________________________ Date: ____________________
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