HEALTHSPRINGS 360 REVIEW OF SYSTEMS CIRCLE IF THE ANSWER IS YES 1. GENERAL a. Do you have fever, chills, or night sweats? b. Have you gained or lost 5 or more pounds lately without trying? c. Have you felt unusually tired or sleepy more so in the last month? d. Do you every doze off at a red light? Do you still feel tired right when you wake up in the morning? 2. HEENT (head, ears, nose throat) a. Do you feel dizzy like the room is spinning or lie you re going to pass out? b. Do you have headaches that are more frequent than normal? c. Do you have blurry vision, pain in your eyes or vision that is getting worse all of a sudden? d. Do you have pain in your ears or hearing that is getting worse to the point that you d like to investigate hearing aids? e. Do you have nose bleeds or troublesome nasal congestion, possibly making it difficult to sleep? f. Do you have pain in your throat or sore in your mouth? g. Do you have pain or bleeding in your gums? h. Has your voice changed or become hoarse? 3. CARDIAC a. DO you have chest pain with exertion r chest pain like a elephant is resting on your chest? b. Does it feel like your heart is racing or skipping beats? c. Do you have shortness at breath with rest or with small amounts of exertion? 4. RESPIRATORY a. Do you feel more short of breath than usual? b. Do you have a new cough? DO you ever cough up blood?
5. GI (gastrointestinal) a. Do you have a problem with recurrent nausea, vomiting, diarrhea or constipation b. Do you have a problem with chronic heartburn or stomach pain? c. Have you noticed blood in your stool? d. Has your stool been black and tarry recently? 6. MUSCULOSKELETAL a. Do you have muscle cramps or pain in your knees, hands or hips? 7. NEUROLOGICAL a. Do you have a new tingling or numbness in your fingers, toes, arms or legs? b. Have you fallen in the last 6 months? 8. SKIN a. Do you bruise now more than you used to? b. Do you have any moles that are growing or changing color or shape? 9. PSYCHIATRIC a. Have you felt depressed or down-and-out over the past 2 months? b. Have you had a loss of interest in things that normally bring you pleasure? c. Have you felt or had a loss of energy recently? 10. ENDOCRINE a. Do you feel hot or cold most of the time? Or when others feel normal? b. Do you experience excessive sweating or night sweats regularly? c. Do you urinate more frequently than you used to? d. Have you noticed an increase or decrease in your appetite? e. Do you feel thirstier now than you used to? 11. HEMATOLOGICAL a. Have you noticed more bruising, nosebleeds, gum bleeds or blood in your urine? 12. GENITOURINARY a. Do you have pain when you urinate? b. Do you have a get up at night and go to the bathroom more than twice? c. Have you had any changes in the number of times you go to the bathroom in the day? d. Do you leak urine, stool or both? e. Do you feel like you need to run to urinate to prevent having an accident? f. DO you have to wear pads to prevent wetting yourself?
FUNCTIONAL ABILITY/ADL ASSESSMENT: 1. Would you consider yourself to be a frail or in poor health? Yes No 2. Because of your health or physical condition, do you have difficulty: Dressing yourself? Yes No Bathing or showering yourself? Yes No Using the toilet alone? Yes No 3. Getting out of a chair or bed? Yes No 4. Walking across the room (use of a cane or walker is OK)? Yes No 5. Walking a quarter of a mile (use a cane or walker is OK)? Yes No 6. Stooping or crouching or kneeling? Yes No 7. Lifting or carrying objects as heavy as 10 pounds? Yes No 8. Handling/grasping small objects, such as a pencil? Yes No 9. Feeding yourself or swallowing food? Yes No 10. Driving or using public transportation? Yes No 11. Shopping for personal items (like toilet items or medications)? Yes No 12. Managing money (like keeping track of expenses or paying bills)? Yes No 13. Doing light housework (like washing dishes or straightening up)? Yes No 14. Preparing meals? Yes No
VISION PROBLEM ASSESSMENT: 1. Do you require glasses/contacts for routine vision? YES NO 2. Does trouble with your vision make it difficult for you to watch TV, play cards, or participate in other activities? YES NO 3. Does trouble with your vision make it difficult for you to read your labels on your medicine bottles? YES NO HEARING LOSS ASSESSMENT: 1. Do you currently have any problems hearing or require hearing aid? YES NO OTHER ASSESSMENT QUESTIONS: 1. Do you have an advance directive? YES NO Is it on file with us? YES NO 2. How often do you exercise? O 1-2 times a week O 2-3 times a week O >3 times a week 3. How does your current physical health compare to last year? O Same O Better O Worse 4. How does your current mental health compare to last year? O Same O Better O Worse 5. Do have any difficulty with eating or meal preparation? YES NO
NAME: DATE: 6. Over the past 2 weeks, have you often been bothered by feeling down, depressed or hopeless? YES NO 7. Over the past 2 weeks, have you been bothered by little or pleasure in doing things? YES NO 8. Over the past 2 weeks, were there any days that you did not take your medication as prescribed? YES NO 9. Many people have trouble taking their medication as prescribed. How often do you miss your doses of medication? O Frequently O A few times a year O A few times a month O A few times a week 10. What factors keep you from taking your medication as directed? O Forgetfulness O Side effects O Cost O Do not understand the directions O Do not understand what the medications are for O Do not think the medication is helping O Do not think medication is necessary. 11. In the past year, have you fallen or been injured from a fall? YES NO 12. Have you ever lost control of your urine? YES NO If so, how big of a problem is it for you? 13. Have you recently lost weight without trying? YES NO 14. Have you ever used tobacco? O Current Type O Former - Date quit How long How much Type 15. On average, how many alcoholic drinks do you have in a day?
16. Have you have more than 4-5 drinks in a day in the past year? YES NO 17. Do you use any recreational/illicit drugs? YES NO 18. What is your marital status? O Single O Married O Divorced O Widowed 19. How do you live? O Alone O Spouse O Family O Institution O Other 20. How often do you have sex without a condom? O Sometimes O Frequently 21. How many sexual partners do you have? O None O One, but I am his/her only partner O One, but he/she has multiple partners O Two/more 22. Do you have any social or financial concerns? YES NO 23. How do you move around? O I walk independently O I use a wheelchair O I walk, but I feel unsteady or need assistance O I am bed bound O I walk with a cane or walker 24. Do you have any difficulty with bathing or grooming? YES NO