Medical History
Name_______________________________________________________ Gender: M F Date of Birth_____________ Age________ _
What is the reason for your visit?________________________________________________________________________________________
Are you taking: Accutane Imitrex Cordarone Prednisone
Medications_________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Drug Allergies: ______________________________________________________________________________________________________
Medical History
Yes No Bleeding Disorder______________________________
Yes No Neurological Disease____________________________
Circle Yes or No
Yes No Heart Disease__________________________________
Yes No Diabetes; taking: Insulin / Medications / Diet-Exercise
Yes No Immune Disease________________________________
Yes No Digestive Disease_______________________________
Yes No Muscle/Skeletal Disease_________________________
Yes No Lung/Breathing Disease__________________________
Yes No Kidney/Bladder Disease_________________________
Yes No Cancer_______________________________________
Yes No Blood Disorder_________________________________
Yes No Mental Health Concerns_________________________
Yes No Skin Disease___________________________________
Yes No Liver Disease__________________________________
Yes No Thyroid Disease________________________________
Yes No Food / Seasonal Allergies________________________
Yes No Epilepsy______________________________________
Yes No Keloid Scars___________________________________
Yes No Other________________________________________
Yes No Currently pregnant or nursed in the last 3 months?
Social History Use of Alcohol: Never Rarely Moderate Daily Use of Tobacco: Never Previously, but not in the past ________ year(s) Current packs/day _________ Use of drugs: : Never Rarely Moderate Daily Eye History
Yes No Other________________________________________
Circle Yes or No
Yes No Do your eyes feel gritty or scratchy?
Yes No Do your eyes frequently turn red?
How often do you use artificial tears?_______________________
Contact Lens Wear
Yes No Eye Surgery_________________________________
What brand or type of contacts do you wear?__________________
Yes No Eye Injury__________________________________
How often do you replace your contacts?_____________________
What type of solution do you use?__________________________
How often do you take your lenses off?______________________
For LASIK, when did you last wear your lenses?______________
________________________________________________________________________________________________
I hereby acknowledge the above to be true to the best of my knowledge.
Signature_________________________________________________________________ Date_________________
Introduction If you have ever nursed a broken arm or leg back to health, you’ll know that bones – despite their appearance – are living tissue that continually rebuild . If we don’t protect our bones, and joints, the bones become thinner and more fragile , making them more likely to break (or fracture). What makes matters worse, is the fact that bone loss takes place ‘sile
Depression in children and young people Factsheet for young people About this factsheet This is one in a series of factsheets for parents, teachers andyoung people entitled Mental Health and Growing Up . The aimsof these factsheets are to provide practical, up-to-dateinformation about mental health problems (emotional,behavioural and psychiatric disorders) that can affect childrenand y
Medical History