Md Eye Care Medical History Form Page 2
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2MD Eye Care, L.L.C. MEDICAL HISTORY QUESTIONNAIRE
FAMILY MEDICAL HISTORY CONTINUED:
Is mother deceased? Y / N
If yes- cause of death?________________________ Age at death?_______
Is father deceased?
Y / N
If yes- cause of death?________________________ Age at death?_______
SOCIAL HISTORY:
(
Circle:) Student Homemaker Employed Retired
(Circle:) Single Married Separated Divorced Widowed
Do you use Tobacco?
Yes / No
Cigarettes / Smokeless
_____ # Packs/Times a Day
______# of Years
Do you use Alcohol?
Yes / No
Rarely
Daily
Weekly
1-2 drinks 2-4 drinks
Other ____________
Substance Abuse?
Yes / No
Rarely
Daily
Weekly
_______________________________________
LIST ANY DRUG ALLERGIES:
_______________________________________________________________________
List all Prescriptions and Over the Counter medications you are taking: (Including Eye Drops)
If you have a list, please give to receptionist to copy in lieu of filling out form:
REVIEWED:
Reason for
Currently Taking
Staff
Date
Medication
Dosage
Taken how often ?
Route
taking
Yes
No
Name
PRN= when needed
__ Oral
___
Times a day
__ Topical
____ or PRN
__ Injection
__ Oral
___
Times a day
__ Topical
____ or PRN
__ Injection
__ Oral
___
Times a day
__ Topical
____ or PRN
__ Injection
__ Oral
___
Times a day
__ Topical
____ or PRN
__ Injection
__ Oral
___
Times a day
__ Topical
____ or PRN
__ Injection
__ Oral
___
Times a day
__ Topical
____ or PRN
__ Injection
__ Oral
___
Times a day
__ Topical
____ or PRN
__ Injection
__ Oral
___
Times a day
__ Topical
____ or PRN
__ Injection
__ Oral
___
Times a day
__ Topical
____ or PRN
__ Injection
__ Oral
___
Times a day
__ Topical
____ or PRN
__ Injection
__ Oral
___
Times a day
__ Topical
____ or PRN
__ Injection
Physician Signature: ___________________________________________
Date: _______________
All information you provide is confidential and will not be released to anyone without your consent
Use back of form for any additional information that you need to add.
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