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* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Social History – You may discuss this portion directly with the doctor if you prefer. [ ] Yes, I prefer to discuss my Social History information only with the doctor. Do you drive? [ ] No [ ] Yes Do you use tobacco products? [ ] No If yes, type/amount/how long _____________ Do you drink alcohol? [ ] No If yes, type/amount/how long ___________________ Do you use illegal drugs? [ ] No If yes, type/amount/how long _________________ Ever been exposed to or infected with [ ] Gonorrhea [ ] Hepatitis [ ] HIV [ ] Syphilis Review of Systems – Do you currently, or have you ever had any problems in the following areas? No Yes ? No Yes ? Constitutional Weight Loss/Gain [ ] [ ] [ ] Integumentary Skin [ ] [ ] [ ] [ ] [ ] [ ] Neurological Headaches Migraines Seizures Eyes Loss of Vision Blurred Vision Distortion/Halos Loss of Side Vision Double Vision Dryness Mucous Discharge Redness Sandy Feeling Itching Burning [ ] [ ] [ ] [ [ [ [ [ [ [ [ [ [ [ Foreign Body Sensation [ Tearing/Watering [ Light Sensitivity [ Eye Pain/Soreness [ Chronic Infection [ Sties or Chalazion [ Flashes/Floaters [ Tired Eyes [ ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] [ ] [ ] [ ] [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] Endocrine Thyroid/Other Glands [ ] [ ] [ ] Psychiatric [ ] [ ] [ ] Ear, Nose, Mouth, Throat Allergies/Hay Fever [ ] [ ] [ ] Hearing Difficulty Ringing in the Ears [ ] [ ] [ ] [ ] [ ] [ ] Respiratory Asthma Chronic Bronchitis Emphysema [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] Vascular/Cardiovascular Diabetes Heart Pain High Blood Pressure Vascular Disease [ [ [ [ [ [ [ [ [ [ [ [ Gastrointestinal Chronic Diarrhea Chronic Constipation [ ] [ ] [ ] [ ] [ ] [ ] Genitourinary Genitals/Kidney/Bladder [ ] [ ] [ ] Bones/Joints/Muscles Rheumatoid Arthritis Muscle Pain Joint Pain [ [ [ [ [ [ [ [ [ [ [ [ Lymphatic/Hematologic Anemia Bleeding Problems [ ] [ ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] [ ] [ ] ] ] ] ] ] ] ] ] [ ] [ ] Allergic/Immunologic [ ] [ ] [ ] Other ______________________________ ___________________________