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MEDICAL HEALTH QUESTIONAIRE SCHONHOFEN OPTOMETRY, PA Name: Date of Birth: Primary Physician: Last Physical Exam: Height: Weight: REVIEW OF SYSTEMS: Please circle any of the following that pertain to you Eyes: Glaucoma Cataract Macular Degen Blurry Vision Flashes Floaters Dryness Watery Eyes Infections Other Cardiovascular: Aneurysm Heart Disease High Blood Pressure Stroke Elevated Cholesterol Phlebitis Other Blood/Lymphatic: Anemia Bleeding Problems Leukemia Breast Cancer Other Musculoskeletal: Arthritis Muscle/Joint Pain Muscle Spasms Muscle Weakness Joint Swelling Integumentary(Skin): Eczema Dermatitis Rosacea Acne Psoriasis Cysts Warts Melanoma Skin Cancer Other Allergic/Immunologic: Allergies Rheumatoid Arthritis Lupus Autoimmune Disease Other Endocrine: Diabetes Type 1/Type 2 Hormonal Dysfunction Cholesterol/Lipid Problems Thyroid Dysfunction: Hyper/Hypo Cancer Other Respiratory: Emphysema Pneumonia Asthma Bronchitis Cancer Other Constitutional: Developmental Disability Unintended Weight Loss Trauma Chronic Fatigue Other Gastrointestinal: Diarrhea Constipation Vomiting Heartburn Ulcers Cancer Other Ears/Nose/Throat: Hayfever Sinus Congestion Dry Mouth Dry Throat Cancer Other Nervous System: Seizures Multiple Sclerosis Headaches/Migraines Paralysis Numbness Other Genitourinary: Ovarian Cancer Vaginal Disorder Uterine Cancer Prostate Cancer Prostate Disorder Kidney Disorder Bladder Disorder Other Mental: Sleep Disorder Depression Anxiety Disorder Mood Changes Bipolar Disorder Other SOCIAL HISTORY: Please circle and answer the following questions. Do you use tobacco products? Yes No Cigarettes/Cigars/ Snuff/ Chew How Long?__ Do you drink alcohol? No Do you use addictive agents? Social (1-2 drinks daily) Yes No What? Have you been infected with: Gonorrhea Syphilis HIV Have you had a blood transfusion? More than 2 drinks daily Frequency Hepatitis None Yes No MEDICATION HISTORY: Please include prescriptions, oral contraceptives, supplements, over the counter, analgesics (acetaminophen, aspirin, etc). MEDICATION ALLERGIES: Please list all known medication allergies. PAST HISTORY: Please list and date any of the following that you answer “yes”. Have you been injured? Yes No Have you had surgery? Yes No Are you currently pregnant? Yes No (Due Date: ) FAMILY HISTORY: Please mark the following conditions that apply to your parents, grandparents, brothers, sisters, or children. Blindness Cataract Crossed eyes Glaucoma Macular Degeneration PATIENT SIGNATURE: Retinal Detachment Retinal Disease Melanoma (eye or otherwise) Cancer Diabetes TODAY’S DATE: Heart Disease High Blood Pressure Elevated Cholesterol Kidney Disease Migraine INITIAL IF NO CHANGE