testing 20 June Step 2admin2023-06-20T06:55:05+00:00 Social History(Please indicate use/former use of the following substances)Tobacco Yes No Former Alcohol Yes No Caffeine Yes No Illicit Drugs Yes No I DON’T USE ANY OF THESE I DON’T USE ANY OF THESE List all current medications and dose (include non-prescription and herbal supplements) None List Attached List Attached Option Do you have any allergies to any medications or substances? Review of Systems (Please indicate if you experience any of the following)Constitutional Weight Loss/Gain Weakness Fatigue Fever Cardiovascular High Blood Pressure Chest Pain Rheumatic Fever Palpitations Have Pacemaker Musculoskeletal Joint Pain Arthritis Muscular Weakness Stiffness Muscular Pain Endocrine Thyroid Trouble Excessive Sweating Excessive Thirst Eyes Glasses or Contacts Blurred Vision Glaucoma Cataracts Excessive Tearing Respiratory Shortness of Breath Cough Wheezing Asthma Bronchitis Skin Rashes Sores Lumps Dryness Itching Hematolymphatic Anemia Easy Bruising Easy Bleeding Swollen Glands Ear/Nose/Mouth/Throat Ears Ringing Earaches Hearing Aid Frequent Colds Nasal Discharge Hay Fever Nosebleeds Dentures Bleeding gums Frequent Sore Throats Gastrointestinal Heartburn Rectal Bleeding Abdominal Pain Gallbladder trouble Hepatitis Neurologic Headache Dizziness Seizures Loss of Sensation Vertigo Immunologic Reactions to Drugs Skin Rashes Reactions to Foods Genitourinary Blood in Urine Urinary Infections Kidney Stones Burning Urination STDs Psychiatric Nervousness Depression Mood Change HiddenCONSENT FOR TREATMENTCONSENT FOR TREATMENT: To the best of my knowledge, the questions on this form have been answered accurately. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the doctor of any changes in my medical status. I also authorize the health care staff to perform the necessary services I may need.Signature of Patient or Parent of Minor Date MM slash DD slash YYYY