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Health History (Past Medical / Review of Systems)
  Last Name
First Name
Date of Birth(mm dd yyyy)
   
Date (mm dd yyyy)
   
  Please check the check box in the column named Yourself if you have been diagnosed or treated for any of the following.
Also check the check box in the column named Family Members to indicate if a blood relative has had any of following.
  Yourself Family Members   Yourself Family Members
Cataracts / Cataract Surgery Color Vision Problem
Corneal Disease Crossed Eyes / Lazy Eye / Amblyopia
Eye Injury/ Eye Surgery Glaucoma
Loss of Vision / Blindness Macula Degeneration
Retinal Disease  
 
AIDS / HIV Alzheimer's / Dementia
Arthritis Artificial Heart Valve
Artificial Joints Autoimmune Disorders
Bleeding Disorders Cancer
Cancer Type (yourself):
Cancer Type (family):
Chemical Dependency Cholesterol / Trigylcerides
Depression / Anxiety Diabetes
Ear, Nose, Throat Problems Epilepsy / Seizures
Gastrointestinal/Acid Reflux Hay Fever / Allergies
Heart Condition/Problems Hepatitis  A  B  C
High Blood Pressure Kidney / Bladder Problems
Lupus Migraine Headaches
Musculoskeletal Problems Neurological Problems
Osteoporosis / Osteopenia Pacemaker
Prostate disease Respiratory Problems
Rheumatic Fever Shingles
Skin Conditions Stroke
Thyroid (high/low/other) Tuberculosis
Other
Allergies to Medications:
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Other Allergies
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Previous Surgeries
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Social History

Marital Status:  Single  Married  Divorced  widowed
Do You Drive?  Yes  No    Limitations:
Do You Smoke? Yes  No    If Yes: Occasional  Frequent    Number of packs per day: