Health History – Review of Systems

health history review of systems

ROS – Review of Systems

The following list shows the content of a systems review that can be incorporated into the patient history.

General/ Constitutional
HIV Status


  • Weight – average, recent changes, minimum, maximum
  • Weakness, fatigue, fever
  • Sweats, chills
  • Anorexia
  • Insomnia (can’t sleep)
  • Hypersomnolence (sleep all the time)


  • Lesions, lumps, growths, sores
  • Moles, change in color/pigmentation, eruptions/rashes
  • Pruritus (itching)
  • Dryness, excessive sweating
  • Easy bruising
  • Changes in nails/hair
  • Birthmarks
  • Change in temperature


  • headache
  • head injury
  • change in size
  • deformity
  • dizziness
  • syncope (lightheaded)
  • vertigo (spinning)


  • Eyes: use of glasses/contacts, pain, diplopia (double vision), glaucoma, cataracts, itching, spots, photophobia, color blindness, night blindness, blurry vision, ptosis (droopy eyelids), halos (rings around lights), scotomata (blind spot), redness, tearing, discharge (color, consistency), use of eye drops, last eye exam
  • Ears: pain, hearing loss, deafness, discharge (color, consistency, bloody), infections, tinnitus (ringing), vertigo, pruritus (itching), use of hearing aid
  • Nose/Sinuses: rhinorrhea (runny nose), nausea, vomiting, hematemesis (vomiting stuffiness, discharge (color, consistency), pruritus (itching), epistaxis (nose bleeds) pain over sinuses, hay fever, frequent colds
  • Throat/Mouth: sores, lesions, condition of teeth and gums, dental caries, loss of teeth, dentures, bleeding, sore throat, hoarseness, change in taste, bad taste, malodorous breath, dry mouth, last dental exam


  • Pain, swelling
  • Limits in range of motion or stiffness
  • Lumps, swollen lymph nodes
  • “Swollen glands”


  • Lumps, pain, swelling
  • Nipple discharge
  • Use of self-exam, last mammogram


  • Cough, sputum (color, quantity), hemoptysis (blood from lungs/bronchus)
  • Wheezing, asthma, emphysema, bronchitis, pneumonia, tuberculosis, pleurisy
  • Shortness of breath
  • Last chest x-ray


  • History of heart disease
  • Chest pain (exertional/nonexertional, associated symptoms)
  • Orthopnea (discomfort breathing by lying flat)
  • PND (Paroxysmal Nocturnal Dyspnea)
  • Dyspnea on exertion (shortness of breath)
  • Edema, cyanosis (blue skin)
  • Palpitations (irregular heartbeats)
  • Loss of consciousness
  • Hypertension, heart murmur
  • Claudication (limping/calf muscle weakness)
  • Thrombophlebitis (inflamed veins)
  • Varicosities (dilated veins)
  • Raynaud’s Phenomenon (bilateral cyanosis of digits)
  • Rheumatic Fever


  • Change in appetite
  • Abdominal pain, difficulty/pain with swallowing Heartburn, indigestion, bloating, belching, blood), jaundice
  • Food intolerance
  • Frequency of bowel movements
  • Change in bowel habits (frequency, consistency, caliber, constipation, diarrhea), melena (dark colored stools), hematochezia (bloody stools), clay-colored stools, mucus (passing mucus)
  • Excessive belching or passing of gas
  • Incontinence (inability to prevent discharge)
  • Hemorrhoids, rectal itching/burning
  • Rectal discharge/pain
  • Laxative use
  • Hepatitis, gallbladder disease


  • Frequency of urination
  • Dysuria (difficulty pain urination)
  • Hematuria (blood in urine)
  • Change in color of urine
  • Polyuria (excess urine)
  • Nocturia (pee a lot at night)
  • Oliguria (not much urine), anuria (no urine)
  • Flank suprapubic pain
  • Retention (can’t fully void)
  • Urgency (desire to void)
  • Hesitancy involuntary delay)
  • Incontinence, change in force of stream
  • Dribbling, passage of air/stone
  • Enuresis (leakage of urine)
  • Past infections


  • Menstrual history (onset cycle duration, amount of flow, change in cycle)
  • LMP amenorrhea (loss of cycle), menorrhagia (excessive menses), metrorhagia (irregular menses), associated pain or PMS symptoms
  • Contraceptive history • Previous pregnancies deliveries, abortions, complications, outcomes) Exposure to DES (diethylstilbestrol) Vaginal discharge, pruritus, abscess, sores, lesions, infections, STI’S, PID (Pelvic Inflammatory Disease), RPR status (Rapid Plasma Reagin test – syphilis). HIV status,
  • Previous PAPs
  • Premenstrual symptoms
  • Problem with intercourse (pain, satisfaction, libido), sexual orientation number of partners
  • Age at menopause
  • Postmenopausal bleeding • Menopausal symptoms (hot flashes, mood swings, changes in vaginal lubrication)


  • Hemias
  • Penile discharge
  • Sores
  • Testicular pain or lumps
  • STI’S
  • RPR (Rapid Plasma Reagin test – syphilis)

HIV status

  • Sexual orientation number of partners
  • Problems with intercourse (impotence satisfaction, sex drive)
  • Contraceptive use


  • Goiter, exophthalmos (eyeballs protrude)
  • Hot/cold intolerance, constipation/diarrhea
  • Tremor, excessive sweating
  • Palpitations, change in voice
  • Skin changes, hair distribution
  • Secondary sex characteristics
  • Changes in body contour or weight
  • Changes in hat glove/shoe size
  • Polyuria (increase urine), polydipsia (increase thirst). polyphagia (increase eating)
  • Striae (stretch marks)
  • Acne, pigmentation
  • Infertility, diabetes, thyroid disorders


  • Pain in an extremity, joint pain
  • Swelling, redness, stiffness, deformity, warmth
  • Limited range of motion,
  • Crepitation (cracking joints) – note location of each joint involved
  • History of arthritis, muscle pain, gout, backache, neck pain, significant trauma


  • Syncope, dizziness, seizures, vertigo
  • Ataxia (uncoordinated movements), limp
  • Frequent falls, tremor involuntary movement
  • Weakness, loss of muscle mass, paralysis
  • Clumsiness, pain
  • Numbness, paresthesia (abnormal sensation, burning, tickling), hyperesthesia (abnormal acuteness to touch), dysarthria (speech change)
  • Changing in handwriting
  • Incontinence (bowel or urine)


  • Anemia, easy bruising
  • Past transfusions and any reactions to them
  • IV drug use, enlarged lymph nodes
  • Hemoglobinopathies (abnormal hemoglobins e.g., sickle cell anemia)


  • Nervousness, anxiety, mood swings, depression, crying spells, panic attacks
  • Change in memory, early awakening problems sleeping, loss of energy
  • Change in libido, suicidal thoughts
  • Change in appetite, binge eating, purging
  • Excessive exercising
  • Paranoia, hallucinations, disturbing thoughts

Health History Assessment

health history assessment

Health History Assessment Purpose

  • A detailed patient history is the most useful diagnostic tool available to any clinician.
  • The main purpose of the patient’s history is to determine the patient’s motives for seeking health care and how their specific ailment is interfering with their daily life.
  • Surveys show that more than 80% of the diagnosis in general outpatient clinics are based on patient interview based on health history assessment.
  • The patient interview should continue through the entire duration of the interaction with them.
  • The best  general patient history technique is to start with open ended questions, and eventual progress to close-ended questions for details.
  • The accuracy of information collected from the patient during the interview (and exam) influence the precision of your diagnosis and treatment.

Patient Medical Charting Guidelines

  • All chart records must remain confidential.
  • Charting must be clear and legible in order to be useful.
  • Do not erase mistakes or remove pages from the chart. If you must erase an error from the patient’s chart, draw a single line through the error/s and initial.
  • If you saw it or did it, chart it.
  • Charting should be done in black ink, labeled, dated and signed by the clinician who examined the patient.

Health History Considerations

Red Flags for More Serious Pathology

  • Violent trauma
  • Carcinoma
  • Systemic steroid use
  • Drug abuse
  • HIV, Hepatitis
  • Recent unexplained weight loss
  • Constant, progressive non-mechanical pain
  • Bowel and/or bladder dysfunction

Signs and Symptoms Red Flags for More Serious Pathology

  • Temperature > 100° F/37.8°C
  • Blood pressure > 160/95 mm Hg
  • Resting pulse > 100 bpm
  • Resting respiration > 25 bpm
  •  Auscultation of bruits – carotid, abdominal
  • Widespread neurological deficits
  • Saddle anaesthesia

Health History Intake Questions


  • What is your occupation?
  • Describe your activities at work. Hours?
  • Do you like your job?


  • Describe your overall fitness level.
  • Do you participate in regular exercise? (describe type, intensity & frequency)

Interests/Other Activities 

  • Do you have any other interests, hobbies or activities you enjoy?


  • Rate your overall diet for me (good, fair, poor)
  • What do you eat for … breakfast? Lunch? Dinner? Snacks?
  • What do you drink throughout the day?
  • How often do you eat … vegetables? Fruit? Sweets? Fast food?
  • How much water do you drink a day?

Living Situation 

  • Can you describe your living situation to me? (house/apt., relationships, etc.)

Sleep Pattern 

  • How many hours do you sleep each night?
  • Have there been any recent changes?
  • Do you feel you get enough sleep?

Bowel Habits 

  • How often do you have a bowel movement? Any recent changes?

Patients over 50

Do you ever notice any rectal bleeding?

Urinary Habits

  • Do you have any problems with urination? Any recent changes? (stopping or starting)


Alcohol: Do you drink alcohol? Type?

How often do you drink? How much?

If you have concern about patient’s drinking:

  • Have you ever felt the need to cut down on drinking?
  • Have you ever felt Annoyed by criticism of drinking?
  • Have you had Guilty feelings about drinking?
  • Have you ever taken a morning “Eye opener?”


  • Do you use or have you ever used tobacco products/smoke? What do you use?
  • How much do you smoke? For how long? When did you stop?


  • Do you use any recreational drugs? What? For how long? (reiterate patient confidentiality if needed)

Domestic Violence

  • Are you currently or have you ever been in a relationship where you were physically hurt or made to feel threatened?

Menses, Menopause 

  • When was the first day of your last menstrual period?
  • Do you have any problems with your menstrual cycle?
  • Have there been any changes in your menstrual cycle? Any abnormal bleeding?

Patients over 50: 

    • Are you still having menstrual periods? If yes, do you remember the first day of your last menstrual period?

Physiologic menopause:

    • At what age did you experience menopause?
    • Did you/are you taking hormone replacement?
    • What? How is it administered?

Surgical menopause: 

    • Why did you have a hysterectomy? (Cancer?)
    • Did they remove your ovaries?
    • Are you taking hormone replacement?

What medication? How is it administered?

Contraceptives, Pregnancies 

  • Contraceptives: Are you using any kind of hormonal contraceptive or an IUD? If yes, what & any problems?
  • Pregnancies: Have you ever been pregnant? If yes, were there any complications?


  • Do you take any prescribed medications?
  • Do you take any over the counter medications?
  • Do you take any vitamins?
  • Have you ever taken medication for extended periods of time?
  • E.g., Steroids, antidepressants, NSAIDs, antibiotics, hormones


  • Do you have any allergies? Food, meds, seasonal

Stress factors/Support System 

  • Have there been any significant stresses in your life lately? (e.g.deaths, divorce, family, work)
  • Have you noticed a change in your ability to handle stress?
  • What resources do you have for support for…?

Past Health History Questions

Serious Illness 

  • Have you ever had any serious illness(es)?
  • Any other problems? Residual effects?


  • Have you ever been hospitalized?
  • Have you had any surgeries?

General Trauma, Accidents, Injury

  • Have you experienced any physical trauma that required treatment or should have been treated?
  • Have you had any accidents? MVA?
  • Were there any residual problems or prolonged side effects?

Diagnostic Imaging (x-ray, MRI) 

  • Have you ever had any x-rays? If yes, why?
  • Were there any problems identified on the x-ray?

Prior Care 

  • Have you ever received prior care?
  • If yes, what for? Describe the care. Did it help?
  • This will tell what has & has not worked previously (huge clinical value)

 Last Physical Exam 

  • When was your last physical exam? Were you experiencing your chief complaint when you had the physical?
  • What was it for?
  • Were any problems identified?


  • When was your last GYN exam & PAP smear?
  • What were the results?

 Females over 50:

  • Have you had a mammogram? How often?
  • What were the results?

Males 15-35: 

  • Do you perform self-testicular exam?
  • Have you ever been taught how to?

Males over 40: 

Have you ever had a rectal exam or lab tests to evaluate your prostate?

  • If yes, do you remember the results?

Family Health History 

  • Are there any conditions that run in your family (diabetes, high blood pressure, stroke, heart disease, cancer)
  • I’d like to start with your mother. Is she alive? Does she have any health problems?
  • How about your mother’s mother?
  • How about your mother’s father?
  • Your father? Your father’s mother? Your father’s father? Brothers? Sisters?
  • If there is a deceased relative, how old were they when they died? Cause of death?
  • Any other health problems in the family?
  • Consider using a family tree in chart notes

Steps in the Assessment of Neuromuscular Conditions

Every outpatient clinical encounter should follow the order below:

1. History

  • Patient Health History form and charting
  • Patient Interview

2. Inspection

  • Inspect the patient’s skin, posture, , body language.
  • Inspect the affected area for swelling , heat, a loss of function, redness and pain (SHARP)

3. Palpation/ Auscultation

4. Motion

  • Active Range of Motion (AROM), Passive Range of Motion (PROM)

5. Neurovascular Screen

6. Referred Pain

  • Visceral, Somatic, Radicular

7. Special Tests

  • Orthopedic Tests, Diagnostic Imaging etc

Likelihood Ratios

likelihood ratio meaning

Likelihood Ratio – Diagnostic Testing

Likelihood Ratios are used to assess two things; 1) the potential usefulness of a particular diagnostic test, and 2) how likely it is that a patient has a condition/disease.

Clinicians need to know which tests will best help or rule – in or rule – out conditions when performing diagnostic tests. The decision to perform a test should be based on the initial assessment of the likelihood of the condition, and how important it is to rule-in or rule-out the condition.

The likelihood of the condition/ disease (“pre-test probability”) need to be assessed. Likelihood ratios tell us how much we should shift our suspicion for a particular test result.

Positive likelihood ratio (LR+)

Positive likelihood ratio is the ratio of positive test results in patients with the pathology (true positives) compared to positive test results in patients without the pathology (false positives). LR+ corresponds to the concept of “ruling-in disease.”

Negative likelihood ratio (LR-)

Negative likelihood ratio is the ratio of negative test results in patients with the pathology (false negatives) compared to negative test results in patients without the pathology (true negatives). LR-corresponds to “ruling-out disease.”

Likelihood Ratio Interpretation

  • LR+ and LR- don’t change as the underlying probability of disease changes (predictive values do change)
  • LR’s using multiple “levels” of positive (i.e. not just a simple positive/negative result) which provide much better, more useful information to you as a clinician and help take into consideration the subtleties of interpreting many physical exam procedures
  • LR+ > 1 indicates an increased probability that disorder is present (bigger number is better)
  • LR- < 1 indicates a decreased probability that disorder is present (smaller number is better)

Likelihood Ratio Table

  • The table below contains general guidelines on the meaning of the values of Likelihood Ratios, which must be correlated with each individual clinical scenario
LR+ Likelihood Ratio Explanation LR-
1-2 Minimal change to post test probability of diagnosis  0.5-1
2-5 Small change to post test probability of diagnosis  0.2-0.5
5-10 Moderate change to post test probability of diagnosis  0.1-0.2
>10 Significant (often conclusive) change to post test probability of diagnosis  <0.1

Specificity – Sensitivity

Sensitivity Specificity Graph

What are Sensitivity & Specificity?

Sensitivity and Specificity describe the accuracy of a test which reports the presence or absence of a condition. Persons for which the condition is satisfied are considered “positive.” Persons for which the condition is not satisfied are considered “negative.”

Test sensitivity is the ability of a test to correctly identify those with the disease (true positive rate). Test specificity is the ability of the test to correctly identify those without the disease (true negative rate).

Sensitivity & Specificity Definition

Sensitivity (SN) Specificity (SP)
– probability of a Positive Test among patients with disease – probability of a Negative Test among patients without disease
– help to identify patients WITH disease (True Positives) – help to identify patients WITHOUT disease (True Negatives)
– highly Sensitive Tests are best used to Rule Out disease – highly Specific Tests are best used to Rule In disease

Sensitivity vs Specificity Graph

Sensitivity Specificity Graph

True Positive (TP), False Positive (FP) , False Negative (FN), True Negative (TN)

Patients WITH Condition Patients WITHOUT Condition
Patients who test POSITIVE (Positive Predictive Value) True Positive (TP) False Positive (FP)
Patients who test POSITIVE (Positive Predictive Value) False Negative (FN) True Negative (TN)


Negative Predictive Value (NPV) Positive Predictive Value (PPV)
Percentage of patients who both test negative and do not have disease (true negatives) Percentage of patients who both test positive and have the disease (true positive)

Sensitivity Specificity Formula


Sensitivity Specificity Formula DEFINTION

Sensitivity (Sen)

= TP/ (TP + FN)
= TP/ Diseased

– percentage of patients with the disease that receive a positive result
– percentage chance that the test will correctly identify a person who actually has the disease

Specificity (Spec)

= TN / (TN + FP)
= TN/ Not Diseased

– percentage of patients without the disease that receive a negative result
– percentage chance that the test will correctly identify a person who is disease-free


Negative Predictive Value (NPV) Positive Predictive Value (PPV)
Percentage of patients who both test negative and do not have disease (true negatives) Percentage of patients who both test positive and have the disease (true positive)

Sensitivity Specificity Example

  • If 100 patients known to have a disease were tested, and 48 test positive, then the test has 48% sensitivity.
  • If 100 with no disease are tested and 94 return a completely negative result, then the test has 94% specificity.


  • Sensitivity and specificity are prevalence-independent test characteristics, as their values are intrinsic to the test and do not depend on the disease prevalence in the population of interest.
  • Sensitivity & specificity by themselves are only useful when they are very high (-95% or higher).
  • Predictive values help answer the question: “Given a positive or negative test result, what is the new probability of disease?”
  • In medical diagnosis, test sensitivity is the ability of a test to correctly identify those with the disease (true positive rate)
  • In medical diagnosis, test specificity is the ability of the test to correctly identify those without the disease (true negative rate).

What are Special Tests?

special-testSpecial Tests are orthopedic diagnostic tests that help identify the nature of musculoskeletal conditions. These special tests are used in creating a proper treatment plan or therapy for a patient’s injury or condition.

Special Tests: Physical Examination

Therapists can tell physical issues by looking for “obvious” signs and symptoms include weak or asymmetrical muscles, improper alignment, swelling, changes in skin color.
Therapists may also perform physical examinations that involve gait analysis, palpation, muscle testing, flexibility testing, and reflex response.


Special Tests: Palpation

Palpation means touching. During the physical examination, your therapist may feel your joints and muscles to see if they are warm or swollen. The therapist may be looking for signs of inflammation. They may apply pressure to a muscle or joint to identify an area of sensitivity, discomfort, pain or tenderness.

Therapists may also place a hand over a joint and ask patients to move the joint, to feel the tendons as they move over the joint, and  to observe if it present signs of pain or discomfort or complain of a “popping or clicking” sensation.

Special Tests: Range of Motion (ROM) Testing

Range of motion tests are used to measure how well a patient can move a joint. Some joints like the thumb hips, and shoulder have a wide range of motion. Other joints like the elbow are like hinges and have a more limited range of motion. Range of motion tests may be active or passive. In active range of motion tests, the patient do all the movement. In passive ROM tests, the therapist will hold the extremity and move it. The therapist may also hold the next joint steady to isolate the movement of the joint being tested.

Special Tests: Flexibility Tests

Flexibility tests are used to measure the range of motion in a joint and are often part of the physical examination. Flexibility testing may be used to help determine whether a patient has muscle imbalance or a condition such as arthritis. Flexibility tests may also help determine the progression of a patient’s condition.

There are several different kinds of flexibility special tests for specific joints and muscles. Therapists may ask patients to reach or bend or to move the affected extremity in certain ways. No preparation is required for the patient, and normally these tests are not painful. If there is any pain during the course of the special testing, patients should not hesitate to communicate this with the therapist.

Special Tests: Muscle Tests

Muscles are soft tissues, and they do not appear on X-rays. This makes muscle testing an important part of the physical examination. Weakness in a muscle may indicate injury to the tendons that connect the muscle to bone, or injury to the nerves that innervate the muscle. Muscle weakness may also indicate generalized weakness of the muscle itself from disuse.To test the strength of muscles, therapists may ask patients to move in certain ways while he or she applies a resistive force.

Special Tests: Stress Tests

Because our bones, muscles and connective tissues  such as ligaments and tendons are constantly responding to pressure, force or stress, therapists may use applied stress to measure their response. For example, a therapist may hold a patient’s forearm still with one hand and move their wrist up and around. This motion applies stress to the ligaments connecting the wrist and the forearm, or the nerve that goes through the carpal tunnel. With these kinds of tests, therapists will be able to identify the nature of the patient’s musculoskeletal condition, and devise a proper treatment plan.