Download Social History – You may discuss this portion directly with the doctor

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
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Integumentary
Skin
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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
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Foreign Body Sensation [
Tearing/Watering [
Light Sensitivity
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Eye Pain/Soreness [
Chronic Infection [
Sties or Chalazion [
Flashes/Floaters
[
Tired Eyes
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Endocrine
Thyroid/Other Glands [ ]
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Psychiatric
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Ear, Nose, Mouth, Throat
Allergies/Hay Fever
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Hearing Difficulty
Ringing in the Ears
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Respiratory
Asthma
Chronic Bronchitis
Emphysema
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Vascular/Cardiovascular
Diabetes
Heart Pain
High Blood Pressure
Vascular Disease
[
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Gastrointestinal
Chronic Diarrhea
Chronic Constipation
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Genitourinary
Genitals/Kidney/Bladder
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Bones/Joints/Muscles
Rheumatoid Arthritis
Muscle Pain
Joint Pain
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Lymphatic/Hematologic
Anemia
Bleeding Problems
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Allergic/Immunologic
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Other ______________________________
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