• MEDICAL HISTORY QUESTIONNAIRE

    THE EYE INSTITUTE OF WYOMING, P.C.
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  • LIST ANY MEDICATION:

    (INCLUDE ORAL CONTRACEPTIVES, ASPRINS, OTC MEDICATIONS, SUPPLEMENTS, AND HOME REMEDIES)
  • MEDICATION ALLERGIES:

  • Review of Systems

    (Please indicate if you have ever had any problems with any of the following areas of your body)
  • CARDIOVASCULAR

  • CONSTITUTIONAL

  • EARS, NOSE, MOUTH, THROAT

  • ENDOCRINE

  • EYES

  • GASTROINTESTINOL

  • GENITOURINARY

  • HEMATOLOGIC

  • INTEGUMENTARY (SKIN)

  • MUSCLE/JOINT/BONES

  • NEUROLOGICAL

  • PHYCIATRIC

  • RESPIRATORY

  • PREGNANT

  • Family History

    (Parents, Grandparents, Siblings, Children) for the following
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  • Social History

    (This can be discussed confidentially with your doctor during the examination)
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  • Should be Empty: