New Patient Questionnaire

Family History

Blindness
Diabetes
High Blood Pressure
Macular Degeneration
Glaucoma

Do you have any of the following problems?

Allergies to medication?
Constitutional (fever, weight loss, other)
Ears/Nose/Mouth (hearing loss, sinus problems, sore throat, other)
Respiratory (asthma, shortness of breath, wheezing, coughing, other)
Gastrointestinal (heartburn, abdominal pain, diarrhea, vomiting, other)
Genitourinary (urinary problems, blood in the urine, other)
Integumentary (skin rashes, excessive dryness)
Musculoskeletal (muscle aches, joint pain, swollen joints, other)
Neurological (numbness, weakness, headaches, paralysis, other)
Hematologic/Lymphatic (blood disorder, leukemia, other)
Allergic/Immunologic (hay fever, allergies, other)
Endocrine (diabetes, thyroid problems)
Cardiovascular (heart problems, chest pain, heart rate sore throat, other)
Psychiatric (depression, anxiety, other)

Social History

Do you smoke or have you ever smoked?
Do you drink alcohol?
If YES, how much?
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Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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