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Demographics
Patient Information
Title
First
Last
MI
Suffix
Nickname
Mr.
Mrs.
Ms.
Miss
Dr.
Rev.
Fr.
Sgt.
Address:
City:
State/ZipCode
AL
AK
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
NE
NH
NJ
NM
NY
NV
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
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
Annulled
Divorced
Domestic partner
Interlocutory
Legally Separated
Married
Never Married
Polygamous
Widowed
Employer / School Name
Primary Doctor
No Doctor Assigned
Dr. Teichmiller, Chris
Misc/Guardian
Primary Care Doctor
ALBRIGHT,MATTHEW
ALLEN, ROBERT
ANDERSON, SCOTT
AWONYI, MOSES
BACK, JOSEPH
BARR, RUSSELL
BASU, ASHISH
BEACH, DON
BHAVSAR,HITESHRI
BRANNING,STEPHAN
CHEATHAM, GREG
COFFEY, CHARLES
CORLISS, BRIAN
DELAVERGNE, TANYA
DONHAM, MICHAEL
DRAKE, BRAD
DUKES, ANDREW
DUPPER, KATHLEEN
FRANCIS, DAVID
GANNAWAY,WILLIAM
GILL, MARLIN
HAGGAG, AKRAM
HALL, ROBERT
HARBIN, STEPHEN
HARNEY, RODNEY
HARRIS, SCOTT
HENDRICKS,MALCOLM
HENDRICKS,TIFFANY
HULL, JEFFREY
IRLE, JOHN
JACKSON,KIRK
JAMES, BRIAN
JOHNSON, JEFFREY
KENNEDY, RACHEL
LIGHT, BEN
LOCKARD, THOMAS
MARQUES, PAUL
MASHBURN, ERIC
MATTHEWS, EDWIN
MATTHEWS, SCOTT
MCCLURE, EMILY
MCELROY, CHAD
MIMMON,IQUABAL
MOSS, ROGER
NONE
NORWOOD, ESTON
PARMER, DAVID
POHL, JAY
POWELL, JOEL
PRICKETT, CHARLES
PURVIS,MARK
PUTMAN, MICHAEL
REDDY, PJM
ROBERTS, NEAL
SCHMIDT, ALLEN
SELJUKI, ADNAN
SMITH,LESLIE
SPARACINO, KATHY
STYERS, SARAH
SWAIN, BERNICE
THOMAS, WAYNE
VAKHARIA, BHARAT
VORA, AMIT
WALKER, ALLEN
WEIRICH, TIMOTHY
WHITLEY, WILLIAM
YOUNG-KING, MELISSA
Billing Information
Is The Billing Address the Same?
Title
First
Last
MI
Suffix
Mr.
Mrs.
Ms.
Miss
Dr.
Rev.
Fr.
Sgt.
Address
City
State
ZipCode
AL
AK
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
NE
NH
NJ
NM
NY
NV
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Home Phone:
Work Phone:
Primary
Insurance Information
Insurance Name:
None
AARP
ADVENTIST RISK MANAGEMENT
AETNA
AETNA PO BOX 981106
AETNA PO BOX 14079
Alliance Seconday Health
Allied
ALWAYS CARE
AMERIBEN
AMERICAN REPUBLIC INSURANCE
ASSURANT HEALTH
BANKERS LIFE AND CASUALTY
BCBS MEDICAL AND VISION
Blue Cross All Kids
BLUE CROSS BLUE SHIELD
Care Credit
Care to Share Card
CGS
CHAMP VA / HEALTH PROVIDERS USA
Charles Pittman
CIGNA
CIGNA-HEALTH SPRING/ WE ARE NOT A PROVIDER
CIGNA HEALTH CARE PO BOX 55270
CIGNA HUNTSVILLE HOSPITAL HEALTH SYSTEMS
CIGNA MEDICAL AND VISION
Cigna/PO BOX 182223
Combined Insurance
CONTINENTAL LIFE INSURANCE
CORESOURCE
COVENTRY HEALTH CARE
DAVIS VISION
EMPLOYEE BENEFIT SERVICES INC
EMPLOYERS CLAIM MANAGEMENT/ WILSON MACHINE
EPS
Equitable & You
EYEMED
Family Life Insurance Co.
FEDERATED INSURANCE MAIL CODE HC07
FIRST COMMUNITY HEALTH PLAN
FIRST HEALTH
GEHA
GERBER LIFE INSURANCE
GOLDEN RULE INSURANCE
GREAT WEST
GREAT WEST HEALTH CARE
Harvard Pilgrim Plan
HUMANA
KAISER PERMANENTE
Key Benefits Adminstrators
Marquette National Life Insurance Co.
Medi-Share
MEDICAID
MEDICAID QMB
Medical Mutual
MEDICARE CAHABA GBA
MERITAIN HEALTH
METLIFE
Metlife Vision
MUTUAL OF OMAHA
NATIONAL ASSOCIATION OF LETTER CARRIERS
NATIONAL RURAL ELECTRIC COOP
National Vision Administration LLC
NECA-IBEW WELFARE TRUST FUND
NEW ERA LIFE INSURANCE
NO INSURANCE
Not a Provider
PALMETTO GBA NATIONAL SUPPLIER CLEARING HOUSE
PALMETTO GBA RAILROAD MEDICARE
PEHP
PENNSYLVANIA LIFE INSURANCE COMPANY
PERDUE HEALTH SMART
PHILADELPHIA AMERICAN LIFE INSURANCE
PHYSCIANS MUTUAL
PITTMAN AND ASSOCIATES
PLASTERS AND CEMENT MASONS LOCAL UNION NO 148
PRINCIPAL LIFE INSURANCE CO/VISION COVERAGE
Private Pay
PROFESSIONAL COURTESY EXAM
Professional Courtesy No Charge
QTC
ROJW HEALTH CARE SUPPORT
SENIOR DEMENSIONS
SIS
SOUTHERN HEALTH PARTNERS
SOUTHLAND
SOUTHLAND NATIONAL VISION
STATE FARM HEALTH INSURANCE
STERLING MEDICARE SUPPLEMENT
SUPERIOR VISION
TENNESSEE VALLEY PAINTERS FUND
Thrivent Financial for Lutherans
TRICARE FOR LIFE MEDICARE SUPPLEMENT
TRICARE PRIME/STANDARD
TVBE
UMR
UMR JOE WHEELER
UNITED COMMERCIAL TRAVELERS
UNITED HEALTH CARE
UNITED HEALTH CARE / ATLANTA GA
Vision Care Direct
VIVA HEALTH/CLAIMS DEPARTMENT
VSP
VSP ACCESS PLAN ONLY
WOODMEN OF THE WORLD
Work Comp
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
ADVENTIST RISK MANAGEMENT
AETNA
AETNA PO BOX 981106
AETNA PO BOX 14079
Alliance Seconday Health
Allied
ALWAYS CARE
AMERIBEN
AMERICAN REPUBLIC INSURANCE
ASSURANT HEALTH
BANKERS LIFE AND CASUALTY
BCBS MEDICAL AND VISION
Blue Cross All Kids
BLUE CROSS BLUE SHIELD
Care Credit
Care to Share Card
CGS
CHAMP VA / HEALTH PROVIDERS USA
Charles Pittman
CIGNA
CIGNA-HEALTH SPRING/ WE ARE NOT A PROVIDER
CIGNA HEALTH CARE PO BOX 55270
CIGNA HUNTSVILLE HOSPITAL HEALTH SYSTEMS
CIGNA MEDICAL AND VISION
Cigna/PO BOX 182223
Combined Insurance
CONTINENTAL LIFE INSURANCE
CORESOURCE
COVENTRY HEALTH CARE
DAVIS VISION
EMPLOYEE BENEFIT SERVICES INC
EMPLOYERS CLAIM MANAGEMENT/ WILSON MACHINE
EPS
Equitable & You
EYEMED
Family Life Insurance Co.
FEDERATED INSURANCE MAIL CODE HC07
FIRST COMMUNITY HEALTH PLAN
FIRST HEALTH
GEHA
GERBER LIFE INSURANCE
GOLDEN RULE INSURANCE
GREAT WEST
GREAT WEST HEALTH CARE
Harvard Pilgrim Plan
HUMANA
KAISER PERMANENTE
Key Benefits Adminstrators
Marquette National Life Insurance Co.
Medi-Share
MEDICAID
MEDICAID QMB
Medical Mutual
MEDICARE CAHABA GBA
MERITAIN HEALTH
METLIFE
Metlife Vision
MUTUAL OF OMAHA
NATIONAL ASSOCIATION OF LETTER CARRIERS
NATIONAL RURAL ELECTRIC COOP
National Vision Administration LLC
NECA-IBEW WELFARE TRUST FUND
NEW ERA LIFE INSURANCE
NO INSURANCE
Not a Provider
PALMETTO GBA NATIONAL SUPPLIER CLEARING HOUSE
PALMETTO GBA RAILROAD MEDICARE
PEHP
PENNSYLVANIA LIFE INSURANCE COMPANY
PERDUE HEALTH SMART
PHILADELPHIA AMERICAN LIFE INSURANCE
PHYSCIANS MUTUAL
PITTMAN AND ASSOCIATES
PLASTERS AND CEMENT MASONS LOCAL UNION NO 148
PRINCIPAL LIFE INSURANCE CO/VISION COVERAGE
Private Pay
PROFESSIONAL COURTESY EXAM
Professional Courtesy No Charge
QTC
ROJW HEALTH CARE SUPPORT
SENIOR DEMENSIONS
SIS
SOUTHERN HEALTH PARTNERS
SOUTHLAND
SOUTHLAND NATIONAL VISION
STATE FARM HEALTH INSURANCE
STERLING MEDICARE SUPPLEMENT
SUPERIOR VISION
TENNESSEE VALLEY PAINTERS FUND
Thrivent Financial for Lutherans
TRICARE FOR LIFE MEDICARE SUPPLEMENT
TRICARE PRIME/STANDARD
TVBE
UMR
UMR JOE WHEELER
UNITED COMMERCIAL TRAVELERS
UNITED HEALTH CARE
UNITED HEALTH CARE / ATLANTA GA
Vision Care Direct
VIVA HEALTH/CLAIMS DEPARTMENT
VSP
VSP ACCESS PLAN ONLY
WOODMEN OF THE WORLD
Work Comp
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:
Tertiary
Insurance Information
Insurance Name:
None
AARP
ADVENTIST RISK MANAGEMENT
AETNA
AETNA PO BOX 981106
AETNA PO BOX 14079
Alliance Seconday Health
Allied
ALWAYS CARE
AMERIBEN
AMERICAN REPUBLIC INSURANCE
ASSURANT HEALTH
BANKERS LIFE AND CASUALTY
BCBS MEDICAL AND VISION
Blue Cross All Kids
BLUE CROSS BLUE SHIELD
Care Credit
Care to Share Card
CGS
CHAMP VA / HEALTH PROVIDERS USA
Charles Pittman
CIGNA
CIGNA-HEALTH SPRING/ WE ARE NOT A PROVIDER
CIGNA HEALTH CARE PO BOX 55270
CIGNA HUNTSVILLE HOSPITAL HEALTH SYSTEMS
CIGNA MEDICAL AND VISION
Cigna/PO BOX 182223
Combined Insurance
CONTINENTAL LIFE INSURANCE
CORESOURCE
COVENTRY HEALTH CARE
DAVIS VISION
EMPLOYEE BENEFIT SERVICES INC
EMPLOYERS CLAIM MANAGEMENT/ WILSON MACHINE
EPS
Equitable & You
EYEMED
Family Life Insurance Co.
FEDERATED INSURANCE MAIL CODE HC07
FIRST COMMUNITY HEALTH PLAN
FIRST HEALTH
GEHA
GERBER LIFE INSURANCE
GOLDEN RULE INSURANCE
GREAT WEST
GREAT WEST HEALTH CARE
Harvard Pilgrim Plan
HUMANA
KAISER PERMANENTE
Key Benefits Adminstrators
Marquette National Life Insurance Co.
Medi-Share
MEDICAID
MEDICAID QMB
Medical Mutual
MEDICARE CAHABA GBA
MERITAIN HEALTH
METLIFE
Metlife Vision
MUTUAL OF OMAHA
NATIONAL ASSOCIATION OF LETTER CARRIERS
NATIONAL RURAL ELECTRIC COOP
National Vision Administration LLC
NECA-IBEW WELFARE TRUST FUND
NEW ERA LIFE INSURANCE
NO INSURANCE
Not a Provider
PALMETTO GBA NATIONAL SUPPLIER CLEARING HOUSE
PALMETTO GBA RAILROAD MEDICARE
PEHP
PENNSYLVANIA LIFE INSURANCE COMPANY
PERDUE HEALTH SMART
PHILADELPHIA AMERICAN LIFE INSURANCE
PHYSCIANS MUTUAL
PITTMAN AND ASSOCIATES
PLASTERS AND CEMENT MASONS LOCAL UNION NO 148
PRINCIPAL LIFE INSURANCE CO/VISION COVERAGE
Private Pay
PROFESSIONAL COURTESY EXAM
Professional Courtesy No Charge
QTC
ROJW HEALTH CARE SUPPORT
SENIOR DEMENSIONS
SIS
SOUTHERN HEALTH PARTNERS
SOUTHLAND
SOUTHLAND NATIONAL VISION
STATE FARM HEALTH INSURANCE
STERLING MEDICARE SUPPLEMENT
SUPERIOR VISION
TENNESSEE VALLEY PAINTERS FUND
Thrivent Financial for Lutherans
TRICARE FOR LIFE MEDICARE SUPPLEMENT
TRICARE PRIME/STANDARD
TVBE
UMR
UMR JOE WHEELER
UNITED COMMERCIAL TRAVELERS
UNITED HEALTH CARE
UNITED HEALTH CARE / ATLANTA GA
Vision Care Direct
VIVA HEALTH/CLAIMS DEPARTMENT
VSP
VSP ACCESS PLAN ONLY
WOODMEN OF THE WORLD
Work Comp
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
Eye History
Reason for Visit:
Secondary Reasons:
Primary Vision Correction:
None
Glasses-Full Time
Glasses-Part Time
Glasses Disance Only
Glasses-Readers Only
Contact Lenses - Soft
Contact Lenses-RGP
GM Lenses
CRT Lenses
Other
Do you have backup glasses?
Yes
No
Other
Planning on new glasses?
Interested In CLs?
Contact Lens Wearers
:
Are they comfortable?
Yes
No
Dryness
Other
Normal Wear Time:
Daily wear
Daily with occasional overnight wear
Extended wear
Rare overnight wear
Other
When do you replace them?:
1 day
1 month
1 week
1 year
2-3 months
2-3 weeks
2 months
2 weeks
3-4 months
3-4 weeks
3 months
4-6 weeks
4 months
6-8 weeks
6 months
Other
Contact Solution:
OPTI-FREE PureMoist
Biotrue
Clear Care
Boston
Equate
Renu
Purilens
Other
Do you have any history of eye conditions?:
Do you take any eye medication?
None
Acular
Alocril
Alphagan P
Alrex
Atropine
Azopt
Bacitracin ung
Bepreve
Besivance
Betagan
Betaxolol
Betimol
Betoptic-S
Bimatoprost
Bion Tears
Biotears
Blephamide solution
Blephamide ung
Blink
Brimonidine
Brinzolamide
Bromday
Celluvisc
Ciloxan
Ciloxan ung
Combigan
Cosopt
Cyclopentolate
Diamox
Dorzolamide
Econopred
Elestat
Emadine
Erythromycin ung
Fish Oil
FML forte suspension
FML solution
FML ung
Gentamicin
Genteal
Genteal
Genteal Liquigel
Homatropine
Hypotears
Hypotears ung
Latanoprost
Levobunolol
LMZ3
Lotemax
Macula Complete
Maxitrol suspension
Maxitrol ung
Medrysone
Metipranolol
Muro-128
Naphcon-A
Nevanac
Ocuflox
Ocupress
Opcon-A
Optipranolol
Optivar
Optive
Pataday
Patanol
Pilocarpine
Polysporin ung
Polytrim
Pred Acetate
Pred Forte
Prednisolone
Pro DHA
Pro Omega
Refresh
Refresh Liquigel
Refresh PM
Refresh Tears
Restasis
rewetting drops
sulfacetamide solution
sulfacetamide ung
Systane
Systane Balance
Systane Liquigel
Systane Ultra
Theratears
Timolol
Timoptic XE
Tobradex
Tobradex ung
Tobramycin
Travatan Z
Trusopt
Unoprostone
Vigamox
Viroptic
Visine
Voltaren
Xalatan
Zaditor
Zirgan
Zylet
Zymar
Other
Last Eye Exam:
1 year
2 years
3 years
Other
By Doctor:
Teichmiller
Ocampo
First exam
Doesn't Remember
Cosco
Decatur Optical
Drake
Jody's Optical
Lens Crafters
Marx Optical
Persall
Potter
Reynolds
Sam's Club
Sears
Target
Wal-Mart
Other
Family Eye History
Does anyone in your family have a history of these eye conditions?
Macular Degen:
No
Father
Mother
Brother
Sister
MGM
PGM
MGF
PGF
Aunt
Uncle
Great-grandparent
Cousin
Other
Glaucoma:
No
Father
Mother
Brother
Sister
MGM
PGM
MGF
PGF
Aunt
Uncle
Great-grandparent
Cousin
Other
Retinal Detach:
No
Father
Mother
Brother
Sister
MGM
PGM
MGF
PGF
Aunt
Uncle
Great-grandparent
Cousin
Other
Cataracts:
No
Father
Mother
Brother
Sister
MGM
PGM
MGF
PGF
Aunt
Uncle
Great-grandparent
Cousin
Other
Crossed/Lazy Eye:
No
Father
Mother
Brother
Sister
MGM
PGM
MGF
PGF
Aunt
Uncle
Great-grandparent
Cousin
Other
Medical History
Vitamins:
None
A
E
C
Zinc
Xanten
Lutein
Other
Over The Counter Meds:
None
Asprin
Acetomenophin
Ibuprofen
Other
Do you have any of these health conditions?:
Good Health
HBP
Elevated Cholesterol
Diabetes
Heart Disease
Thyroid Disease
Arthritis
Asthma
COPD
Cancer
Migraine
Headaches
Seizure Disorder
Other
Injuries, Surgeries, Hospitalizations:
Pregnant Or Nursing:
No
Yes
Unsure
Other
Primary Care Physician:
Doesn't Have One
Doesn't Remember
None
Dr. Whitley
Dr. Jackson
Dr. Young-King
Dr. Reddy
Dr. Bhavasar
Dr. Irle
Dr. Mashburn
Dr. John Johnson
Dr. Prickett
Dr. Matthews
Dr. Harbin
Dr. Hull
Dr. Cheatham
Dr. Parmer
Dr. Mize
Dr. Wilson
Dr. Beach
Dr. Gillispie
Dr. Allen
Dr. Frances
Other
Last Visit:
1 week
1 month
3 months
6 months
1 year
2 years
Other
Reason:
Check up
Annual
Other
Family Medical History:
None
Diabetes
HBP
Heart Disease
Cancer
Thyroid
Other
Unknown family history
Occupation:
Student
Police officer
Teacher
Nurse
Salesman
Firefighter
Engineer
Other
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
Cigaretts
Chewing Tobacco
Other
How Long:
Alcohol Use:
No
Yes
Occasionally
Socially
Other
Type:
None
Beer
Wine
Hard Liquor
Other
How Long:
Illegal Drug Use:
No
Yes
Other
Type:
How Long:
Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Unknown
Patient Declined to Specify
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
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
General:
None
Negative
Other
Fever, weight loss, weight gain, fatigue?
Ear/Nose/Throat:
None
Allergies
Sinus Problems
Chronic Cough
Dry Throat / Mouth
Hard of Hearing
Other
Allergies, Sinus, Cough, Dry Mouth / Throat
Cardiovascular:
None
Vascular Disease
HBP
Heart Surgery
Other
High BP, Heart Surgery, Vascular Disease
Respiratory:
None
Asthma
Bronchitis
Emphysema
COPD
Other
Asthma, Bronchitis, Emphysema, COPD
Genitourinary:
None
painful urination
frequent urination
impotence
yellow jaundice
kidney stones
Other
Kidney Stones, Frequent Urination, impotence
Musculoskeletal:
None
joint pain
stiffness
swelling
cramps
arthritis
Other
Arthritis, Joint Pains, Head or Neck Injury
Skin:
None
pimples, warts
growths
rash
Other
growths, rashes, acne
Neurological
None
numbness, paralysis
headache
seizures
migraines
Other
Headaches, migraines, seizures
Psychiatric
None
anxiety
depression
insomnia
Other
Depression, Anxiety, Insomnia
Endocrine:
None
diabetes
hypothyroid
hyperthoyroid
Other
Thyroid, Diabetes
Blood/Lymph:
None
bleeding
cholestrolemia
anemia
Other
Anemia, cholesterol, bleeding problems
Immune:
None
sneezing
swelling
redness
itching
hives
lupus
Other
Seasonal Allergies, Rheumatoid, AIDS, Lupus, STD
Gastrointestinal:
None
Diarrhea
Constipation
Ulcer
Acid Reflux
Other
Diarrhea, Constipation, Ulcer, Reflux
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