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Medical History
First Name
Last Name
Date Of Birth
Emergency Contact Name, Relationship, and Phone Number:
Are you in good health?
Have there been any changes in your general health within the past year?
Date of Your Last Physical Exam
Are you now under the care of a Physician?
Name of Physician/Medical Provider Facility? Phone Number of Physician?
Have you ever been hospitalized for any surgical operation or serious illness?
Preferred Pharmacy, Phone Number, and Location:
Medications
Have you taken Viagra, Revatio, Cialis, or Levitra in the last 24 hours?
Do you wear contact lenses?
Have you ever taken Fen-Phen/Redux?
Have you ever taken Fosamax, Boniva, Actonel, or any cancer medications containing Bisphosphonates?
Are you currently taking any medications?
Please List any Medications and Reason (or you may upload your medication list below):
You may upload or take a photo of your medication list rather than typing out if you prefer.
Upload
or drag files here
Tobacco and Substance Use
Do you use tobacco?
If yes, please specify method and frequency.
Do you or have you ever used controlled substances?
If yes, please specify method and frequency.
Allergies
Local Anesthetics like Novocaine Allergy
What anesthetics? What reaction?
Codeine Allergy
What reaction?
Ibuprofen Allergy
What reaction?
Iodine Allergy
What reaction?
Latex Allergy
What reaction?
NSAIDs Allergy
What reaction?
Penicillin Allergy
What reaction?
Sulfa Allergy
What reaction?
Do you have any other allergies not listed above?
If yes, please explain and include reaction.
Medical History
Have you ever, or do you currently, have any of the following?
Abnormal Bleeding
Abnormal Blood Pressure
AIDS/HIV
High or Low? Are you medicated for?
Allergies
Anemia
Antibiotic Premedication for Dental Appointments
Please specify your allergies and any reactions:
What condition requires a premedication?
Arthritis
Artificial Joints
Back Problems
Which joints were replaced? When? Who was your surgeon?
Blood Disease
Blood Thinners, Use of
Cancer
Blood Disease, please explain:
What Blood thinners are you taking and what dose? What and when was your last INR?
Cancer, Type and When:
Chemical Dependency
Chemotherapy/Radiation
Cortisone Treatments
Cough, Persistent or Bloody
Diabetes
Eating Disorder
Diabetes, Type:
Eating Disorder Diagnosis and When Diagnosed:
Emphysema
Epilepsy or Seizure History
Fainting or Dizziness
Glaucoma
Headaches
Head/Neck/Oral Cancer
Heart Murmur
Hepatitis
Herpes/Cold Sores
Hepatitis Type:
HPV
HPV Vaccine
Jaundice
When did you receive the HPV vaccine?
Jaw Pain
Kidney Disease
Liver Disease
Memory Loss
Mitral Valve Prolapse
Pacemaker
Psychiatric Care
Rapid Weight Loss or Gain
Respiratory Disease
Psychiatric Diagnosis:
Rheumatic Fever
Shortness of Breath
Sinus Problems
Stroke
Swelling of Extremities
Thyroid Condition
Tuberculosis
Ulcer
Have you ever had any disease, condition, or problem not lilsted above?
If yes, please explain.
For Women
Are you a woman?
Are you Pregnant?
When are you due?
Are you Nursing?
Are you taking birth control?
To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform the doctor if I, or my minor child, ever have a change in health.
Patient/Legal Guardian Signature
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