Social History Staff initials [PDF]

BARNHORST EYE ASSOCIATES. Medical/Social History. Staff initials and Date: ______ ______ ______ ______ ______ ______ ___

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Idea Transcript


BARNHORST EYE ASSOCIATES Medical/Social History Patient name:__________________________________ Past Surgical History (list any type of surgery you have had or indicate “NONE”)

Social History Current Occupation: _______________________ Alcohol use: Never / Occasional / Daily Do you have: HIV / Hepatitis (type_____) / No

Marital Status: M / D / S / W Do you drive? Yes / No Do you smoke? _____Yes _____No 1ppd

Have you ever had an allergic reaction to a medication? _____Yes _____No Name of medication you are allergic to:

Reaction:

Medications Please list any medications/supplements you are currently taking below or indicate “NONE”:

Personal Medical/Family History Do you or any of the listed family members have/had any of the following?: Medical Condition Endocrine (diabetes, thyroid, etc.) Cardiovascular (heart, high blood pressure, etc.) Respiratory (asthma, emphysema, COPD, etc.) Gastrointestinal (stomach ulcers, intestinal disease, etc.) Genital, Urinary, Kidney (prostate) Bone, Joint, Muscular (arthritis, etc.) Skin (acne, rash, cancer, warts, etc.) Neurological (multiple sclerosis, etc.) Allergic, Immunologic (hay fever, lupus, sjogren’s, etc.) Blood, Lymph (anemia, cholesterol, etc.) Cancer – specify type ( ) Psychiatric (anxiety, depression, etc.) General / Constitutional ( fever, weight change, fatigue, etc.) Other – specify ( ) Cataracts Glaucoma Macular Degeneration

Staff initials and Date: ______

______ ______

______

Patient Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N

______

______

M-Mother F-Father S-Sibling GP-Grandparent Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N

______

______

BARNHORST EYE ASSOCIATES Medical/Social History

Staff initials and Date: ______

______ ______

______

______

______

______

______

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