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

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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
[
]
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]
]
]
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]
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Endocrine
Thyroid/Other Glands [ ]
[ ]
[ ]
Psychiatric
[ ]
[ ]
[ ]
Ear, Nose, Mouth, Throat
Allergies/Hay Fever
[ ]
[ ]
[ ]
Hearing Difficulty
Ringing in the Ears
[ ]
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[ ]
[ ]
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Respiratory
Asthma
Chronic Bronchitis
Emphysema
[ ]
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[ ]
[ ]
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Vascular/Cardiovascular
Diabetes
Heart Pain
High Blood Pressure
Vascular Disease
[
[
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[
[
[
Gastrointestinal
Chronic Diarrhea
Chronic Constipation
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
Genitourinary
Genitals/Kidney/Bladder
[ ]
[ ]
[ ]
Bones/Joints/Muscles
Rheumatoid Arthritis
Muscle Pain
Joint Pain
[
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Lymphatic/Hematologic
Anemia
Bleeding Problems
[ ]
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Allergic/Immunologic
[ ] [ ] [ ]
Other ______________________________
___________________________