Bryan Vekovius, M.D.

2121 Fairfield Ave. Suite 120

Shreveport, LA. 71104

318-675-3733


Name__________________________Date of Birth_______________Date___________

Name of Referring Physician______________________________Age_______________

Name of Family Physician__________________________________________________

Review of Systems

Do you currently or have you ever had a problem with any of the following?

YES    NO

□          □                      Ear, Nose, Mouth, Throat_________________________________

□          □                      Cardiovascular (Heart/High Blood Pressure)__________________

□          □                      Respiratory  (Lung/Breathing)_____________________________

□          □                      Gastrointestinal (Stomach/Intestines)________________________

□          □                      Genitourinary (Genital/Kidneys/Bladder)____________________

□          □                      Musculoskeletal (Muscle/Arthritis/Joints)____________________

□          □                      Integumentary (Skin)____________________________________

□          □                      Neurological/Psychiatric (Depression/Nerves)_________________

□          □                      Endocrine (Diabetes/Thyroid/etc.)__________________________

□          □                      Hematologic (Anemia/Bleeding Tendencies)__________________

□          □                      Lymphatic (Swelling)____________________________________

□          □                      Allergic/Immunologic____________________________________

 

Do you have any allergies to any medication?___________________________________

________________________________________________________________________
List any surgeries you have had:______________________________________________

________________________________________________________________________

List all medications you are currently taking:____________________________________

________________________________________________________________________

________________________________________________________________________

Family and Social History:

Do any of your family members have any of the following diseases?

YES   NO                                                       

□          □      Glaucoma

□          □      Retinal/Macular Degeneration 

□          □      Cancer

□          □      High Blood Pressure

□          □      Kidney Disease

□          □      Cataracts

□          □      Arthritis

□          □      Diabetes

□          □      High Blood Pressure

□          □     Stroke

Do you smoke?                        □  No      □  Yes      How many packs per day?_______

Do you drink alcohol?                        □  No     □  Yes How often?__________________

 

______________________________                                      ___________________

Physician’s Signature                                                      Date

Tech Review              _____________        _____________              ______________

                                   Initials/Date               Initials/Date                     Initials/Date