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Medical History Questionnaire

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MEDICAL HISTORY

  • FAMILY HISTORY

    Please note any family history (parents, grandparents, siblings, children; living or deceased) for the following conditions:
  • SOCIAL HISTORY

  • REVIEW OF SYSTEMS

    Do you currently, or have you ever had any problems in the following areas?
  • NoYes?
    Fever, Weight Loss/Gain
  • NoYes?
    Integumentary (Skin)
  • NoYes?
    Headaches
    Migraines
    Seizures
  • NoYes?
    Loss of Vision
    Blurred Vision
    Distorted Vision/Halos
    Loss of Side Vision
    Double Vision
    Dryness
    Mucous Discharge
    Redness
    Sandy or Gritty Feeling
    Itching
    Burning
    Foreign Body Sensation
    Excess Tearing/Watering
    Glare/Light Sensitivity
    Eye Pain or Soreness
    Chronic Infection of Eye/Lid
    Styies or Chalazion
    Flashes/Floaters in Vision
    Tired Eyes
  • NoYes?
    Thyroid/Other Glands
  • NoYes?
    Allergies/Hay Fever
    Sinus Congestion
    Runny Nose
    Post-Nasal Drip
    Chronic Cough
    Dry Throat/Mouth
  • NoYes?
    Asthma
    Chronic Bronchitis
    Emphysema
  • NoYes?
    Diabetes
    Heart Pain
    High Blood Pressure
    Vascular Disease
  • NoYes?
    Diarrhea
    Constipation
  • NoYes?
    Genitals/Kidney/Bladder
  • NoYes?
    Rheumatoid Arthritis
    Muscle Pain
    Joint Pain
  • NoYes?
    Anemia
    Bleeding Problems
  • NoYes?
    Allerical/Immunologic
  • NoYes?
    Psychiatric
  • MM slash DD slash YYYY
x

Mask Policy
updated Feb. 16, 2023
In light of New York’s lifting the mask mandate, as of February 12, 2023, masks are no longer considered mandatory at our office.

We still request that any patients or staff who have been around anyone with COVID, RSP, or the Flu, to please, out of respect for all of our patients and staff, continue to wear a mask while in our public space.

We appreciate everyone’s kindness and understanding.