Sequatchie Valley Eye Care

Today's Date:

Name:

First Last

Date of Birth

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Social Sec. Number:

Phone:

Cell Phone:

Spouse:

First Last

Spouse Date of Birth:

Guardian:

First Last

Guardian Phone:

Name of Medical Doctor:

Last Physical:

E-mail address:

Employer:

Are you allergic to any medications or food?

Yes
No

Please list the food/medications that you are allergic to:

Please list ALL prescription & OTC medications you currently take:

If unable to name your medications, please list your pharmacy and we will contact them to get a list.

Review of Systems: Please check if you currently or recently have had any of the following:

Constitutional

Chronic Fever
Unexpected Weight Changes
Fatigue

Integumentary

Skin Problems
Skin Cancer
Dryness
Bruises Easily
Changes in existing moles

Neurological

Headaches
Migraines
Seizures
Tremors
Muscle Weakness
Numbness & Tingling

Endocrine

Diabetes Type 1
Diabetes Type 2
High Blood Sugar
Low Blood Sugar
Thyroid Disease
Gout

Gastrointestinal

Diarrhea or Constipation
Abdominal Pain
Crohns Disease
Colitis

Psychiatric

Anxiety
Depression
Panic Disorder
Confusion
Bi-polar Disorder

Genitourinary

Genitals/Kidney/Bladder
Dialysis
Prostrate Disorder

Ear, Nose, Throat

Allergies/Hay Fever
Dry Mouth
Sinus Congestion
Hearing Loss

Respiratory

Asthma
Chronic Bronchitis
Emphysema
COPD

Cardiovascular

Hypertension
High Cholesterol
Vascular Disorder
Stroke

Muscular

Rheumatoid Arthritis
Osteoarthritis
Joint/Muscular Pain

Lymphatic/Immunologic

Anemia
Bleeding Disorders
Lupus
Cancer

What type of Cancer did you have?

Please list any other conditions that you have that isn't listed above: