New Patient Form

Demographics

Title First Last MI Suffix Nickname Mr.. Mrs. Ms. Dr. Rev. Fr. Miss

Address:
City:		State/ZipCode	TX AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN UT VA VI VT WA WI WV WY

Home Phone:		Work Phone:
Other Phone:		Alerts:
Cell Phone:		Preferred Contact Method:	Home Phone Work Phone Cell Phone Other Phone Text Message Email
SSN		Email
Birthday		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status	Single Married Separated Divorced Widowed Unknown	Employer/School Name
Primary Doctor	No Doctor Assigned Dr. Manuel, Francis K. Dr. Burfield, Hannah	Misc/Guardian

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev. Fr. Miss

Address

City	State	ZipCode
	TX AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN UT VA VI VT WA WI WV WY

Home Phone:
Work Phone:

Primary

Insurance Information

Insurance Name:	None AARP Aetna American Medical Security American National Insurance Co. Assurant Health / PHCS Assurant Health Aetna Bankers Life & Casuality Benefit Planner Inc. Benefits Management Inc. Blue Cross Blue Shield Of Texas Boon Chapman Benefits Administrator Care Improvement Plus Cigna Health Care Continentala CoreSource Coventry Health Care Dallas General Life Insurance Company Eyemed First Health Arizona First Health Network GEHA Golden Rule Insurance Company GWH-Cigna Hartford Life and Accident Healthfirst HealthFirst TPA Humana - Kentucky Humana Vision Care Plan Insurance TPA Kelsey Care Advantage Key Benefits Administrator Medicare Memorial Hermann HNP Meridian Health Meritain Health Mutual of Omaha Companies NALC Health Benefit Plan Nationwide Life Insurance Company Old Surety Life Insurance Company One Health Plan Opticare Vision Plans Palmetto GBA PHCS GPA PHCS Group Administrators PHCS Mega Life PHCS Smith Administrators Physicians Mutual Pittman & Associates Principle Life Insurance Company Provident American Life & Health Insurance Company RHA Administrators, Inc. Royal Neighbors of America Select Care of Texas LLC Sentinal Security Life Insurance Co Smith Administrators PHCS Southern Health Plan Service State Farm Health Insurance Superior Vision Plan Texan Plus Texas True Choice Transamerican Life Insurance Company Tricare True Choice USA UMR Unicare United American Insurance Company United Health Care USAA Life Insurance Group USFHP / DOD Vision Service Plan WellCare Woodmen of the World
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary

Insurance Information

Insurance Name:	None AARP Aetna American Medical Security American National Insurance Co. Assurant Health / PHCS Assurant Health Aetna Bankers Life & Casuality Benefit Planner Inc. Benefits Management Inc. Blue Cross Blue Shield Of Texas Boon Chapman Benefits Administrator Care Improvement Plus Cigna Health Care Continentala CoreSource Coventry Health Care Dallas General Life Insurance Company Eyemed First Health Arizona First Health Network GEHA Golden Rule Insurance Company GWH-Cigna Hartford Life and Accident Healthfirst HealthFirst TPA Humana - Kentucky Humana Vision Care Plan Insurance TPA Kelsey Care Advantage Key Benefits Administrator Medicare Memorial Hermann HNP Meridian Health Meritain Health Mutual of Omaha Companies NALC Health Benefit Plan Nationwide Life Insurance Company Old Surety Life Insurance Company One Health Plan Opticare Vision Plans Palmetto GBA PHCS GPA PHCS Group Administrators PHCS Mega Life PHCS Smith Administrators Physicians Mutual Pittman & Associates Principle Life Insurance Company Provident American Life & Health Insurance Company RHA Administrators, Inc. Royal Neighbors of America Select Care of Texas LLC Sentinal Security Life Insurance Co Smith Administrators PHCS Southern Health Plan Service State Farm Health Insurance Superior Vision Plan Texan Plus Texas True Choice Transamerican Life Insurance Company Tricare True Choice USA UMR Unicare United American Insurance Company United Health Care USAA Life Insurance Group USFHP / DOD Vision Service Plan WellCare Woodmen of the World
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Vision-Primary

Insurance Information

Insurance Name:	None AARP Aetna American Medical Security American National Insurance Co. Assurant Health / PHCS Assurant Health Aetna Bankers Life & Casuality Benefit Planner Inc. Benefits Management Inc. Blue Cross Blue Shield Of Texas Boon Chapman Benefits Administrator Care Improvement Plus Cigna Health Care Continentala CoreSource Coventry Health Care Dallas General Life Insurance Company Eyemed First Health Arizona First Health Network GEHA Golden Rule Insurance Company GWH-Cigna Hartford Life and Accident Healthfirst HealthFirst TPA Humana - Kentucky Humana Vision Care Plan Insurance TPA Kelsey Care Advantage Key Benefits Administrator Medicare Memorial Hermann HNP Meridian Health Meritain Health Mutual of Omaha Companies NALC Health Benefit Plan Nationwide Life Insurance Company Old Surety Life Insurance Company One Health Plan Opticare Vision Plans Palmetto GBA PHCS GPA PHCS Group Administrators PHCS Mega Life PHCS Smith Administrators Physicians Mutual Pittman & Associates Principle Life Insurance Company Provident American Life & Health Insurance Company RHA Administrators, Inc. Royal Neighbors of America Select Care of Texas LLC Sentinal Security Life Insurance Co Smith Administrators PHCS Southern Health Plan Service State Farm Health Insurance Superior Vision Plan Texan Plus Texas True Choice Transamerican Life Insurance Company Tricare True Choice USA UMR Unicare United American Insurance Company United Health Care USAA Life Insurance Group USFHP / DOD Vision Service Plan WellCare Woodmen of the World
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Vision-Secondary

Insurance Information

Insurance Name:	None AARP Aetna American Medical Security American National Insurance Co. Assurant Health / PHCS Assurant Health Aetna Bankers Life & Casuality Benefit Planner Inc. Benefits Management Inc. Blue Cross Blue Shield Of Texas Boon Chapman Benefits Administrator Care Improvement Plus Cigna Health Care Continentala CoreSource Coventry Health Care Dallas General Life Insurance Company Eyemed First Health Arizona First Health Network GEHA Golden Rule Insurance Company GWH-Cigna Hartford Life and Accident Healthfirst HealthFirst TPA Humana - Kentucky Humana Vision Care Plan Insurance TPA Kelsey Care Advantage Key Benefits Administrator Medicare Memorial Hermann HNP Meridian Health Meritain Health Mutual of Omaha Companies NALC Health Benefit Plan Nationwide Life Insurance Company Old Surety Life Insurance Company One Health Plan Opticare Vision Plans Palmetto GBA PHCS GPA PHCS Group Administrators PHCS Mega Life PHCS Smith Administrators Physicians Mutual Pittman & Associates Principle Life Insurance Company Provident American Life & Health Insurance Company RHA Administrators, Inc. Royal Neighbors of America Select Care of Texas LLC Sentinal Security Life Insurance Co Smith Administrators PHCS Southern Health Plan Service State Farm Health Insurance Superior Vision Plan Texan Plus Texas True Choice Transamerican Life Insurance Company Tricare True Choice USA UMR Unicare United American Insurance Company United Health Care USAA Life Insurance Group USFHP / DOD Vision Service Plan WellCare Woodmen of the World
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical History

Chief Complaint (please explain the reason for your visit):

Duration:	1 day 2 days 3 days 4 days 5 days 6 days 1 week 1 month 3 months 6 months 1 year Today Years Childhood	Quality:	no change worse better constant throbbing	Severity:	Mild Moderate Severe	Location:	Both Right Left Temporal Lids Parietal Occipital Frontal
Associated:	dizzy headache loss of vision blurred vision eye pain visual changes floaters flashes	Modifying:	Medication Glasses help Drops help Medication not tried	Context:	computer outside Seasonal Driving white wall/blue sky	Timing:	Always Sometimes AM PM Afternoons Mornings

Secondary Complaints

Primary Care Physician:

Pregnant Or Nursing:

No Yes Unsure

Medications (Please list any medications you're currently taking below): No Current Medications

None Glyburide Hydrocortisone Glucophage Metformin Methlyprednisolone Prednisone Actos Amaryl Humulin Novalog Prempro Premarin Synthroid Amiodarone Atenolol Captopril Clonidin Furosamide Lasix HCTZ Zestril Altase Cozar Crestor Diovan Lipitor Albuterol Allegra Flonase Nasacort Singular Proventil Pepcid Zantac Protonix Detrol Flomax Xanax Wellbutrin Buspar Valium Prozac Ritalin Adderall Effexor Zoloft Diclofenac Lortab MS Contin Oxycodone Celebrex Carbamazepine Depakote Topamax Dilantin Coumadin Plavix Bactroban Cipro Acyclovir Cefzil Amoxycillin Augmentin Tetracycline Levaquin Plaquenil Lunell Cyclessa Other	None Glyburide Hydrocortisone Glucophage Metformin Methlyprednisolone Prednisone Actos Amaryl Humulin Novalog Prempro Premarin Synthroid Amiodarone Atenolol Captopril Clonidin Furosamide Lasix HCTZ Zestril Altase Cozar Crestor Diovan Lipitor Albuterol Allegra Flonase Nasacort Singular Proventil Pepcid Zantac Protonix Detrol Flomax Xanax Wellbutrin Buspar Valium Prozac Ritalin Adderall Effexor Zoloft Diclofenac Lortab MS Contin Oxycodone Celebrex Carbamazepine Depakote Topamax Dilantin Coumadin Plavix Bactroban Cipro Acyclovir Cefzil Amoxycillin Augmentin Tetracycline Levaquin Plaquenil Lunell Cyclessa Other	None Glyburide Hydrocortisone Glucophage Metformin Methlyprednisolone Prednisone Actos Amaryl Humulin Novalog Prempro Premarin Synthroid Amiodarone Atenolol Captopril Clonidin Furosamide Lasix HCTZ Zestril Altase Cozar Crestor Diovan Lipitor Albuterol Allegra Flonase Nasacort Singular Proventil Pepcid Zantac Protonix Detrol Flomax Xanax Wellbutrin Buspar Valium Prozac Ritalin Adderall Effexor Zoloft Diclofenac Lortab MS Contin Oxycodone Celebrex Carbamazepine Depakote Topamax Dilantin Coumadin Plavix Bactroban Cipro Acyclovir Cefzil Amoxycillin Augmentin Tetracycline Levaquin Plaquenil Lunell Cyclessa Other	None Glyburide Hydrocortisone Glucophage Metformin Methlyprednisolone Prednisone Actos Amaryl Humulin Novalog Prempro Premarin Synthroid Amiodarone Atenolol Captopril Clonidin Furosamide Lasix HCTZ Zestril Altase Cozar Crestor Diovan Lipitor Albuterol Allegra Flonase Nasacort Singular Proventil Pepcid Zantac Protonix Detrol Flomax Xanax Wellbutrin Buspar Valium Prozac Ritalin Adderall Effexor Zoloft Diclofenac Lortab MS Contin Oxycodone Celebrex Carbamazepine Depakote Topamax Dilantin Coumadin Plavix Bactroban Cipro Acyclovir Cefzil Amoxycillin Augmentin Tetracycline Levaquin Plaquenil Lunell Cyclessa Other
None Glyburide Hydrocortisone Glucophage Metformin Methlyprednisolone Prednisone Actos Amaryl Humulin Novalog Prempro Premarin Synthroid Amiodarone Atenolol Captopril Clonidin Furosamide Lasix HCTZ Zestril Altase Cozar Crestor Diovan Lipitor Albuterol Allegra Flonase Nasacort Singular Proventil Pepcid Zantac Protonix Detrol Flomax Xanax Wellbutrin Buspar Valium Prozac Ritalin Adderall Effexor Zoloft Diclofenac Lortab MS Contin Oxycodone Celebrex Carbamazepine Depakote Topamax Dilantin Coumadin Plavix Bactroban Cipro Acyclovir Cefzil Amoxycillin Augmentin Tetracycline Levaquin Plaquenil Lunell Cyclessa Other	None Glyburide Hydrocortisone Glucophage Metformin Methlyprednisolone Prednisone Actos Amaryl Humulin Novalog Prempro Premarin Synthroid Amiodarone Atenolol Captopril Clonidin Furosamide Lasix HCTZ Zestril Altase Cozar Crestor Diovan Lipitor Albuterol Allegra Flonase Nasacort Singular Proventil Pepcid Zantac Protonix Detrol Flomax Xanax Wellbutrin Buspar Valium Prozac Ritalin Adderall Effexor Zoloft Diclofenac Lortab MS Contin Oxycodone Celebrex Carbamazepine Depakote Topamax Dilantin Coumadin Plavix Bactroban Cipro Acyclovir Cefzil Amoxycillin Augmentin Tetracycline Levaquin Plaquenil Lunell Cyclessa Other	None Glyburide Hydrocortisone Glucophage Metformin Methlyprednisolone Prednisone Actos Amaryl Humulin Novalog Prempro Premarin Synthroid Amiodarone Atenolol Captopril Clonidin Furosamide Lasix HCTZ Zestril Altase Cozar Crestor Diovan Lipitor Albuterol Allegra Flonase Nasacort Singular Proventil Pepcid Zantac Protonix Detrol Flomax Xanax Wellbutrin Buspar Valium Prozac Ritalin Adderall Effexor Zoloft Diclofenac Lortab MS Contin Oxycodone Celebrex Carbamazepine Depakote Topamax Dilantin Coumadin Plavix Bactroban Cipro Acyclovir Cefzil Amoxycillin Augmentin Tetracycline Levaquin Plaquenil Lunell Cyclessa Other	None Glyburide Hydrocortisone Glucophage Metformin Methlyprednisolone Prednisone Actos Amaryl Humulin Novalog Prempro Premarin Synthroid Amiodarone Atenolol Captopril Clonidin Furosamide Lasix HCTZ Zestril Altase Cozar Crestor Diovan Lipitor Albuterol Allegra Flonase Nasacort Singular Proventil Pepcid Zantac Protonix Detrol Flomax Xanax Wellbutrin Buspar Valium Prozac Ritalin Adderall Effexor Zoloft Diclofenac Lortab MS Contin Oxycodone Celebrex Carbamazepine Depakote Topamax Dilantin Coumadin Plavix Bactroban Cipro Acyclovir Cefzil Amoxycillin Augmentin Tetracycline Levaquin Plaquenil Lunell Cyclessa Other
None Glyburide Hydrocortisone Glucophage Metformin Methlyprednisolone Prednisone Actos Amaryl Humulin Novalog Prempro Premarin Synthroid Amiodarone Atenolol Captopril Clonidin Furosamide Lasix HCTZ Zestril Altase Cozar Crestor Diovan Lipitor Albuterol Allegra Flonase Nasacort Singular Proventil Pepcid Zantac Protonix Detrol Flomax Xanax Wellbutrin Buspar Valium Prozac Ritalin Adderall Effexor Zoloft Diclofenac Lortab MS Contin Oxycodone Celebrex Carbamazepine Depakote Topamax Dilantin Coumadin Plavix Bactroban Cipro Acyclovir Cefzil Amoxycillin Augmentin Tetracycline Levaquin Plaquenil Lunell Cyclessa Other	None Glyburide Hydrocortisone Glucophage Metformin Methlyprednisolone Prednisone Actos Amaryl Humulin Novalog Prempro Premarin Synthroid Amiodarone Atenolol Captopril Clonidin Furosamide Lasix HCTZ Zestril Altase Cozar Crestor Diovan Lipitor Albuterol Allegra Flonase Nasacort Singular Proventil Pepcid Zantac Protonix Detrol Flomax Xanax Wellbutrin Buspar Valium Prozac Ritalin Adderall Effexor Zoloft Diclofenac Lortab MS Contin Oxycodone Celebrex Carbamazepine Depakote Topamax Dilantin Coumadin Plavix Bactroban Cipro Acyclovir Cefzil Amoxycillin Augmentin Tetracycline Levaquin Plaquenil Lunell Cyclessa Other	None Glyburide Hydrocortisone Glucophage Metformin Methlyprednisolone Prednisone Actos Amaryl Humulin Novalog Prempro Premarin Synthroid Amiodarone Atenolol Captopril Clonidin Furosamide Lasix HCTZ Zestril Altase Cozar Crestor Diovan Lipitor Albuterol Allegra Flonase Nasacort Singular Proventil Pepcid Zantac Protonix Detrol Flomax Xanax Wellbutrin Buspar Valium Prozac Ritalin Adderall Effexor Zoloft Diclofenac Lortab MS Contin Oxycodone Celebrex Carbamazepine Depakote Topamax Dilantin Coumadin Plavix Bactroban Cipro Acyclovir Cefzil Amoxycillin Augmentin Tetracycline Levaquin Plaquenil Lunell Cyclessa Other	None Glyburide Hydrocortisone Glucophage Metformin Methlyprednisolone Prednisone Actos Amaryl Humulin Novalog Prempro Premarin Synthroid Amiodarone Atenolol Captopril Clonidin Furosamide Lasix HCTZ Zestril Altase Cozar Crestor Diovan Lipitor Albuterol Allegra Flonase Nasacort Singular Proventil Pepcid Zantac Protonix Detrol Flomax Xanax Wellbutrin Buspar Valium Prozac Ritalin Adderall Effexor Zoloft Diclofenac Lortab MS Contin Oxycodone Celebrex Carbamazepine Depakote Topamax Dilantin Coumadin Plavix Bactroban Cipro Acyclovir Cefzil Amoxycillin Augmentin Tetracycline Levaquin Plaquenil Lunell Cyclessa Other

Drug Allergies:

No Known Drug Allergies Codeine Penicillin Sulfa Aspirin Compazine Erythromyacin Ceclor Other No Known Drug Allergies

Injuries, Surgeries, Hospitalizations:

FAMILY MEDICAL HISTORY: Diabetes, HBP, Heart Dz, Cancer, Athritis, Lupus, Kidney, Thyroid, Other

OCULAR HISTORY

Last Comprehensive: 1 year 2 years 3 years 4 years 5 years > 5 years First Never Doctor: Manuel Iszard Robinson Unknown

Ocular History (ex: cataracts, macular degeneration, glaucoma, retinal detachment, crossed/lazy eye etc.):

Ocular Surgeries:


Ocular Medications (Please list any ocular medications you're currently taking below):
None Restasis Oasis Oasis Plus ATs Gel Tears Systane Refresh EZ Tears Restore Pred Forte Lotemax FML Maxitrol Blephamide Bacitracin Lastacaft Pataday Besivance Zymaxid Azasite Doxycycline Xalatan Travatan Trav Z Lumigan Latanoprost Zioptan Simbrinza Azopt Cosopt Alphagan Combigan Timoptic Timolol None Restasis Oasis Oasis Plus ATs Gel Tears Systane Refresh EZ Tears Restore Pred Forte Lotemax FML Maxitrol Blephamide Bacitracin Lastacaft Pataday Besivance Zymaxid Azasite Doxycycline Xalatan Travatan Trav Z Lumigan Latanoprost Zioptan Simbrinza Azopt Cosopt Alphagan Combigan Timoptic Timolol None Restasis Oasis Oasis Plus ATs Gel Tears Systane Refresh EZ Tears Restore Pred Forte Lotemax FML Maxitrol Blephamide Bacitracin Lastacaft Pataday Besivance Zymaxid Azasite Doxycycline Xalatan Travatan Trav Z Lumigan Latanoprost Zioptan Simbrinza Azopt Cosopt Alphagan Combigan Timoptic Timolol None Restasis Oasis Oasis Plus ATs Gel Tears Systane Refresh EZ Tears Restore Pred Forte Lotemax FML Maxitrol Blephamide Bacitracin Lastacaft Pataday Besivance Zymaxid Azasite Doxycycline Xalatan Travatan Trav Z Lumigan Latanoprost Zioptan Simbrinza Azopt Cosopt Alphagan Combigan Timoptic Timolol None Restasis Oasis Oasis Plus ATs Gel Tears Systane Refresh EZ Tears Restore Pred Forte Lotemax FML Maxitrol Blephamide Bacitracin Lastacaft Pataday Besivance Zymaxid Azasite Doxycycline Xalatan Travatan Trav Z Lumigan Latanoprost Zioptan Simbrinza Azopt Cosopt Alphagan Combigan Timoptic Timolol

FAMILY OCULAR HISTORY

Glaucoma: No Yes Parent Sibling Grandparent Macular Degen: No Yes Parent Sibling Grandparent Cataracts: No Yes Parent Sibling Grandparent Retinal Detach: No Yes Parent Sibling Grandparent Crossed / Lazy: No Yes Parent Sibling Grandparent


SOCIAL HISTORY

Hobbies:

Astronomy Art Baseball Boating Basketball Cooking Crafts Dancing Diving Football Fishing Golf Gardening Horseback Riding Hunting Models Needlepoint None Painting Photography Piano Reading Running Roller Blading Softball Sewing Skiing Soccer Swimming Tennis Video Games Woodworking Other

Smoking Status:	Never smoker (<100 cigs equiv) Former smoker (no longer smokes) Current some day smoker (not daily) Light smoker (<10 cigs/day) Heavy smoker (>10 cigs/day) Smoker (current status unknown) Current every day smoker Unknown if ever smoked Other	Type:	None Chewing Tobacco Cigarettes Cigars Pipe Other
Alcohol Use:	No Yes In Past Social Other	Type:	None Beer Wine Hard Liquor All Other
Illegal Drugs:	No Yes Other	Type:	None Other

Race:

American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other Race Patient Declined to Specify Other

Ethnicity:

Hispanic or Latino Not Hispanic or Latino Unknown Patient Declined to Specify Other

Preferred Language:

English Spanish French Patient Declined to Specify Abkhazian Afar Afrikaans Akan Albanian Amharic Arabic Aragonese Armenian Assamese Avaric Avestan Aymara Azerbaijani Bambara Bashkir Basque Belarusian Bengali Bihari languages Bislama Bokm?l, Norwegian), Norwegian Bokm?l Bosnian Breton Bulgarian Burmese Catalan; Valencian Central Khmer Chamorro Chechen Chichewa; Chewa; Nyanja Chinese Church Slavic; Old Slavonic; Church Slavonic; Old Bulgarian; Old Church Slavonic Chuvash Cornish Corsican Cree Croatian Czech Danish Divehi; Dhivehi; Maldivian Dutch; Flemish Dzongkha Esperanto Estonian Ewe Faroese Fijian Finnish Fulah Gaelic; Scottish Gaelic Galician Ganda Georgian German Greek, Modern (1453-) Guarani Gujarati Haitian; Haitian Creole Hausa Hebrew Herero Hindi Hiri Motu Hungarian Icelandic Ido Igbo Indonesian Interlingua (International Auxiliary Language Association) Interlingue; Occidental Inuktitut Inupiaq Irish Italian Japanese Javanese Kalaallisut; Greenlandic Kannada Kanuri Kashmiri Kazakh Kikuyu; Gikuyu Kinyarwanda Kirghiz; Kyrgyz Komi Kongo Korean Kuanyama; Kwanyama Kurdish Lao Latin Latvian Limburgan; Limburger; Limburgish Lingala Lithuanian Luba-Katanga Luxembourgish; Letzeburgesch Macedonian Malagasy Malay Malay Malayalam Maltese Manx Maori Maori Marathi Marshallese Mongolian Nauru Navajo; Navaho Ndebele, North; North Ndebele Ndebele, South; South Ndebele Ndonga Nepali Northern Sami Norwegian Norwegian Nynorsk; Nynorsk, Norwegian Occitan (post 1500) Ojibwa Oriya Oromo Ossetian; Ossetic Pali Panjabi; Punjabi Persian Polish Portuguese Pushto; Pashto Quechua Romanian; Moldavian), Moldovan Romansh Rundi Russian Samoan Sango Sanskrit Sardinian Serbian Shona Sichuan Yi; Nuosu Sindhi Sinhala; Sinhalese Slovak Slovenian Somali Sotho, Southern Sundanese Swahili Swati Swedish Tagalog Tahitian Tajik Tamil Tatar Telugu Thai Tibetan Tigrinya Tonga (Tonga Islands) Tsonga Tswana Turkish Turkmen Twi Uighur; Uyghur Ukrainian Urdu Uzbek Venda Vietnamese Volap?k Walloon Welsh Western Frisian Wolof Xhosa Yiddish Yoruba Zhuang; Chuang Zulu Other

Review of Systems

Please select an option from each menu, and select "Other" where needed to type in an option not included in the drop down. Thank you!

GENERAL: Fever, Weight Loss, Weight Gain, Fatigue?	None Other Fever Weight Loss Weight Gain Fatigue
EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat	None Other Allergies Sinus Problems Chronic Cough Dry Throat / Mouth Hard of Hearing Cough
CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease	None Other High BP Surgery Vascular Disease Stroke
RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD	None Other Asthma Bronchitis Emphysema COPD
GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination, Impotence	None Other Kidney Stones Painful Urination Frequent Urination Impotence Yellow Jaundice
MUSCLES, BONES, JOINTS: Arthritis, Joint Pains, Head or Neck Injury	None Other Arthritis Joint Pain Stiffness Swelling Cramps Head or Neck Injury
SKIN: Growths, Rashes, Acne	None Other Growths Rash Acne Warts Cancer
NEUROLOGICAL: Headaches, Migraines, Seizures	None Other Headache Migraines Seizures Numbness Tingling Paralysis Stroke
PSYCHIATRIC: Depression, Anxiety, Insomnia	None Other Depression Anxiety Insomnia Bipolar Manic
ENDOCRINE: Thyroid, Diabetes	None Other Thyroid Issue Hypothyroid Hyperthyroid Diabetes
BLOOD/LYMPH: Anemia, Cholesterol, Bleeding Problems	None Other Cholesterolemia Anemia Bleeding Bruising
ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, AIDS, Allergy Shots, Lupus	None Other Sneezing Swelling Redness Itching Hives Rash Rheumatoid Lupus MS
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Acid Reflux	None Other Diarrhea Constipation Ulcer Acid Reflux
STD History:	None Other Chlamydia Gonococcal Herpes HIV Aids

Notes:

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