Medical History Questionnaire Our forms are secured using 256-bit encryption and our servers meet HIPAA-complaint standards. "*" indicates required fields Patient name* Primary care provider name and address* In a few words, what brings you in today?*Since this problem began, have you experienced any of the following:Check all that apply. Seasonal allergies Hay fever Chest pain Congestive heart failure Irregular heart rhythm Fever Weight loss (unintended) Rash Skin problems Vomiting Stomach ulcers Diarrhea Blood in stool Genital ulcers Urinary or genital discharge Kidney stones Blood in urine Sinus problems Post-nasal drip Runny nose Dry mouth Hearing loss Headaches Migraines Paralysis Joint aches Muscle aches Cough Bronchitis Shortness of breath Asthma attack Wheezing Other Please list any other symptoms not listed aboveEye HistoryDo you have, or have you ever been treated for, any of the conditions listed below?Check all that apply Dry eyes Macular degeneration Glaucoma Cataracts Retinal detachment Keratoconus Lazy/crossed eye Uveitis/iritis Do you wear glasses?*Select OneYesNoAre they for reading, distance, or both?*Select OneReadingDistanceBothHow old are your eyeglasses?* Have you ever had eye surgery, including LASIK or other refractive surgeries, or an eye injury?*Select OneYesNoPlease list your eye surgeries and/or injuries and their dates:*Do you wear contacts? If so, what kind? Do you sleep in them?Select OneYesNoMedical HistoryDo you have, or have you ever been treated for, any of the conditions listed below? High blood pressure Heart problems Osteoarthritis Rheumatoid arthritis COPD/emphysema Asthma Stroke Thyroid problems Type 1 diabetes Type 2 diabetes LDL Stomach ulcers Cancer Kidney problems Stroke Migraines Sleep apnea Blood disorder Skin problems Autoimmune disease Migraines Tuberculosis HIV Hepatitis If you have diabetes, what was your last hemoglobin A1c? What is your usual fasting blood sugar? Please list any other health problems not listed abovePlease list any surgeries you have had and their datesHave you had a flu vaccine this year?*Select OneYesNo, for medical reasonsNo, for non-medical reasonsHave you had a pneumonia vaccine this year?*Select OneYesNo, for medical reasonsNo, for non-medical reasonsCurrent MedicationsPlease list all medications you currently take, including any supplementsAllergies and Medication IntolerancesPlease list any allergies and medication intolerances, as well as the reactions you experienceSocial HistoryDo you currently smoke?*Select OneYesNoWhat and how much do you smoke?* At what age did you start smoking?* Are you a former smoker?*Select OneYesNoAt what age did you quit smoking?* Does anyone in your immediate family smoke?*Select OneYesNoWho in your immediate family smokes?* How often do you drink alcohol?*Select OneDailyWeeklySeveral times a monthNeverType of Alcohol* Family Medical HistoryHave any of your blood relatives had or been treated for any of the following conditions? If so, write their relationship to you in the field.High Blood Pressure Heart Problems Osteoarthritis Rheumatoid arthritis Lung problems Stroke Thyroid problems Diabetes High cholesterol Stomach ulcers Cancer Dry eyes Macular degeneration Glaucoma Cataracts Retinal detachment Keratoconus Lazy/crossed eye CAPTCHA
