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Medical History Form

Medical History Form

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Published by bbies

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Published by: bbies on Nov 19, 2009
Copyright:Attribution Non-commercial

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01/10/2013

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MEDICAL HISTORY FORM
1.
Name:
______ 
 
 ____________ 
Date
 __________________________________ 2.
Did another doctor refer you to Dr. Biesman? If yes, please provide his/her name, address, and telephone number
:_____________________________________________________________________________________________ 3.
What is the name and address of your family doctor
? ________________________________________________ 4.
Who is your regular eye doctor
?
MD or OD
? _______________________________________________________ 5.
Are you allergic to any medications?
YES NO
If yes, what are they?
 _________________________________  _____________________________________________________________ 
If yes, describe your reaction (s)
 _________________________________________________________________ 6.
Medical History: Have you ever had: Date of Onset
a.Diabetes mellitusYESNO_______________________________________Diet control ___Oral agents ___Insulin __ b.Heart attackYES NO_______________________________________Angina or chest painYES NO_______________________________________Heart failureYES NO _______________________________________Irregular heart beatYES NO_______________________________________c.High blood pressureYESNO_______________________________________d.Stroke or "mini stroke"YES NO_______________________________________e.AnemiaYES NO_______________________________________fAsthma, emphysema, tuberculosisYESNO ________________________________________ g.Liver disease, hepatitis, jaundiceYES NO_______________________________________h.Stomach ulcersYES NO_______________________________________i.Kidney disease or stonesYESNO_______________________________________ j.Arthritis(if yes, specify type)YES NO_______________________________________k. Skin cancerYES NO_______________________________________l.Other types of cancer (location)YES NO_______________________________________m.Thyroid diseaseYES NO_______________________________________Overactive___Underactive___ Treatment______ _______________________________________n.SeizuresYES NO_______________________________________o.Blood clots in legsYES NO_______________________________________p.Bleeding disorders or easy bruisingYES NO_______________________________________q.HIV positive or AIDSYESNO_______________________________________r.Other medical problemsYES NO_______________________________________7.
Review of Systems: Have you recently experienced or are you currently experiencing:
a. Unexplained weight lossYES NO_______________________________________b. Skin rashes or soresYES NO_______________________________________c. HeadacheYES NO_______________________________________d. Sinus trouble or nosebleedsYES NO_______________________________________

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