 |
| Name* : |
|
| DOB(mm-dd-yyyy)* : |
|
| Age(Years)* : |
|
| Name of Referring Physician : |
|
| 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 |
| |
| YES NO |
Cardiovascular (Heart/High Blood Pressure) |
| |
| YES NO |
Respiratory (Lung/Breathing) |
| |
| YES NO |
Gastrointestinal (Stomach/Intestines) |
| |
| YES NO |
Genitourinary (Genital/Kidneys/Bladder) |
| |
| YES NO |
Musculoskeletal (Muscle/Arthritis/Joints) |
| |
| YES NO |
Integumentary (Skin) |
| |
| YES NO |
Neurological/Psychiatric (Depression/Nerves) |
| |
| YES NO |
Endocrine (Diabetes/Thyroid/etc.) |
| |
| YES NO |
Hematologic (Anemia/Bleeding Tendencies) |
| |
| YES NO |
Lymphatic (Swelling) |
| |
| YES NO |
Allergic/Immunologic) |
| |
| Do you have any allergies to any medication? |
|
| |
| Currently taking any medication?List them |
|
| |
| List any surgeries you have had: |
|
| |
Family and Social History:
Do any of your family members have any of the following diseases? |
| |
| YES NO Glaucoma |
YES NO Cataracts |
| |
| YES NO Retinal/Macular Degeneration |
YES NO Arthritis |
| |
| YES NO Cancer |
YES NO Diabetes |
| |
| YES NO Heart Attack |
YES NO High Blood Pressure |
| |
| YES NO Kidney Disease |
YES NO Stroke |
| |
| YES NO Other : |
| |
| Do you smoke? YES NO How many packs per day? |
| |
| Do you drink alcohol? YES NO How often? |
| |
(A copy will be sent to Dr. Vekovius Office) |
