MEDICAL HISTORY QUESTIONAIRRE



FORT WORTH EYE ASSOCIATES

PLEASE FILL OUT COMPLETELY

NAME: _______________________________Date of Birth: __________________________

MEDICAL HISTORY QUESTIONNAIRE

DRUG ALLERGIES: ________________________________________________ □ NONE

PLEASE CHECK ONLY CONDITIONS/ SYMPTOMS THAT YOU ARE CURRENTLY EXPERIENCING OR HAVE HAD IN THE PAST:

Constitutional: Respiratory: Integumentary: Immunologic:

□ Fatigue □ Shortness of □ Acne □ Food allergies

□ Fever breath □ Rosacea □ Seasonal allergies

□ Weight Loss □ Wheezing □ Rash □ Immune disorders

□ Chills □ Cough □ Change in hair □ NONE

□ Sweats □ Difficulty texture

□ NONE breathing □ Change in nails Endocrine:

□ NONE □ Skin cancer □ Diabetes

□ NONE □ Thyroid disorder

E N T: Gastrointestinal: □ Hypoglycemia

□ Dry Mouth □ Reflux Musculoskeletal: □ Memory loss

□ Earache □ Diarrhea □ Gout □ NONE

□ Nasal congestion □ Nausea □ Arthritis

□ Nosebleeds □ Vomiting □ Joint pain Psychiatric:

□ Sore throat □ Indigestion □ Back pain □ Depression

□ Sinus pain □ Constipation □ NONE □ Panic disorder

□ Chronic cough □ Ulcers □ Anxiety

□ NONE □ NONE Neurological: □ NONE

□ Dizziness

Cardiovascular: Genitourinary: □ Headaches Other:

□ Chest pain □ Urination □ Slurred speech □ Pregnant or

□ Palpitations □ STD □ Memory loss Breastfeeding

□ Leg edema □ Kidney ailment □ Gait disturbance □ Other

□ Increased heart rate □ NONE □ Swollen glands ___________

□ Stroke □ Loss of

□ Heart attack coordination

□ High Blood pressure □ NONE

□ High Cholesterol

□ NONE Hematologic:

□ Enlarged lymph nodes

□ Abnormal bleeding

□ Swollen glands

□ NONE

Turn Page Over

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download