Personal Medical History-Lifestyle 2022 "*" indicates required fields Preferred FIRST name:* Date* MM slash DD slash YYYY Please check if any of the following APPLIES to you, and list any medications for each condition that you check. Cardiovascular: Hypertension/High blood pressure High Cholesterol Stroke/CVA Congestive Heart Failure Heart Disease None Medication: Endocrine: Non-insulin Dependent Diabetes (TYPE 1 OR 2) Insulin Dependent Diabetes (Type 1 or 2 ) Thyroid Dysfunction Hormonal Dysfunction None Medication: Respiratory: Asthma Emphysema Bronchitis Chronic Obstruction Sleep Ap nea None Medication: Neurological: Multiple Sclerosis Epilepsy Tumor Migraine Autism Cerebral Palsy None Medication: Musculoskeletal: Osteoarthritis Fibromyalgia Ankylosing Spondylitis Muscular Dystrophy Arthritis Osteoporosis Gout None Medication: Immunologic: Lupus Rheumatoid Arthritis Sjogren’s Syndrome None Medication: Constitutional: Cancer Fatigue Syndrome Developmental Disability None Medication: Genitourinary: Kidney Disease Prostate Disorder STD Pregnant Nursing None Medication: Psychiatric: Attention Deficit Anxiety Depression Bipolar Disorder None Medication: Hematologic/Lymphatic Anemia Blood Loss Ulcer None Medication: Gastrointestinal Crohn’s Colitis Ulcer Acid Reflux Celiac Disease None Medication: Ear/Nose/Throat: Hearing Loss Sinusitis Dry Mouth Laryngitis None Medication: Integumentary: Eczema Rosacea Psoriasis Herpes – Cold Sores/Shingles None Medication: Allergies (please list) None Drug:Environmental:Alcohol Use: Yes No Amount: Tabacco Use (current): Yes No Amount: Previous Use? Yes No Please list any medications (including supplements and vitamins) that you are taking that were not listed above:Have you ever had an eye surgery? (Lasik, cataract surgery, eye injury repair, etc.) Yes No FAMILY HISTORY: Have you or anyone in your family (Parents, siblings, children, living or deceased) ever been diagnosed with? Cataracts: Yes No Who Glaucoma: Yes No Who? Macular Degeneration: Yes No Who? Amblyopia (Lazy eye): Yes No Who? Cancer: Yes No Who? Diabetes: Yes No Who? High Blood Pressure: Yes No Who? Signature*Date* MM slash DD slash YYYY
