Patient Health Questionnaire - Luxe Laser Center | Maumee ...
Patient Health QuestionnaireName: _________________________________________ Date of Birth: ______/_______/______Do you have any medication allergies? ____ Yes____ NoIf so, please list: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Review of Systems:To the best of your knowledge, do you now have or have you ever had the following: Yes No Yes NoCONSTITUTIONALMUSCULAR/SKELETALUnexplained Chills Curvature of the Spine Unexplained Fever Arthritis/Joint Pain Significant Weight Gain Difficulty Walking Significant Weight Loss SKINEYESBruise Easily Double Vision Psoriasis Vision Problems Eczema EAR/NOSE/THROATNEUROLOGICLack of Sense of Smell Polio Hearing Loss Stroke CARDIACHead Injury High Blood Pressure Numbness of Arm/Leg Heart Attack PSYCHOLOGICALIrregular Heart Rate Depression Pacemaker Drug/Alcohol Dependency Rheumatic Fever Psychiatric Treatment RESPIRATORYENDOCRINEAsthma or Wheezing Diabetes Shortness of Breath Thyroid Disorder Chronic Cough HEMATOLOGIC/LYMPHSleep Apnea Anemia GI TRACTSwollen Glands Liver Disease Immune Disease/AIDS Stomach Ulcer Blood Clots Chronic Heartburn Pulmonary Emboli Hiatal Hernia ALLERGY/IMMUNOLOGICGENITAL/URINARYIodine Urinary Tract Infection Shellfish Kidney of Bladder Disease Latex Difficulty Urinating SOCIAL HISTORYDo you smoke? ____ Yes ____ No(Number of packs/day ____ for ____ years)Do you drink? ____ Yes ____ No(Number of drinks/week ____)Are you married ____ Yes ____ NoDo you live alone? ____ Yes ____ NoLevel of Education: ____________________________________________________________________________________________________________PAST HISTORYAny medical history not covered in previous questions? ___________________________________________________________________________________________________________________________________________________________________________________________________________Are you pregnant or think you may be? ____ Yes ____ NoSurgeries/Hospitalization Reason Year1. __________________________________________________________________________________________________________________________2. __________________________________________________________________________________________________________________________3. __________________________________________________________________________________________________________________________4. __________________________________________________________________________________________________________________________Medication that you are currently taking:Medication Dosage When you started taking1. __________________________________________________________________________________________________________________________2. __________________________________________________________________________________________________________________________3. __________________________________________________________________________________________________________________________4. __________________________________________________________________________________________________________________________ ................
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