Patient Medical History Form Page 2
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2PATIENT MEDICAL HISTORY FORM
Allergies
Y/N
Explain:
____________________________________________________________________
List
any
medications
you
are
currently
taking:_________________________________________________
List
your
past
Ocular
History
and
General
Medical
History:
______________________________________
Medical History Required by your Insurance Company
No
Yes
No
Yes
Musculoskeletal
Self/ Family
Respiratory
Self/
Family
Arthritis
Chronic Bronchitis
Joint pain
Emphysema
Neurological
Hematologic/Lymphatic
Seizures
Anemia
Other
Bleeding problems
Genitourinary
Swelling
Kidneys
Cardiovascular
Bladder
Heart problems
Constitutional
Vascular disease
Fever
Endocrine
Weight loss
Thyroid problems
Weight gain
Other glands
Gastrointestinal
Allergic/Immunologic
Ulcers
Hay fever
Other
Medicine allergies
Ears, Nose, Mouth, Throat
Systemic allergies
Sinus problems
Psychiatric
Chronic cough
Dry mouth/throat
Chronic ear infections
Have you ever been exposed to or infected with:
Gonorrhea
Y/N
Hepatitis
Y/N
2 |
P a g e
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Parent category: Medical