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Medical History Form
Last, First, Middle
Email
Heart Problems
Yes
No
Chest pain
Yes
No
Shortness of breath
Yes
No
Blood pressure problem
Yes
No
Heart murmur
Yes
No
Heart valve problem
Yes
No
Taking heart medication
Yes
No
Rheumatic fever
Yes
No
Pacemaker
Yes
No
Artificial heart valve
Yes
No
Blood Problems
Yes
No
Easy bruising
Yes
No
Frequent nosebleeds
Yes
No
Abnormal bleeding
Yes
No
Blood disease (anemia)
Yes
No
Ever require a blood transfusion?
Yes
No
Allergy Problems
Yes
No
Hay fever
Yes
No
Abnormal bleeding
Yes
No
Sinus problems
Yes
No
Skin rashes
Yes
No
Taking allergy medication
Yes
No
Asthma
Yes
No
Intestinal Problems
Yes
No
Ulcers
Yes
No
Weight gain or loss
Yes
No
Special diet
Yes
No
Constipation/Diarrhea
Yes
No
Kidney or bladder problems
Yes
No
Bone or Joint Problems
Yes
No
Arthritis
Yes
No
Back or neck pain
Yes
No
Joint replacement(e.g., total hip, pins, or implants)
Yes
No
Are you taking or have you taken Bisphosphonate(e.g., Fosamax, Boniva, Actonel, Atelvia, Reclast , etc.)
Yes
No
Fainting Spells, Seizures, or Epilepsy
Yes
No
Stroke(s)
Yes
No
Frequent or severe headaches
Yes
No
Thyroid problems
Yes
No
Persistent cough or swollen glands
Yes
No
Premedications required by physician
Yes
No
Cancer/Tumor
Yes
No
Diabetes
Yes
No
Urinate more than 6 times a day
Yes
No
Thirsty or mouth is dry much of the time
Yes
No
Family history of diabetes
Yes
No
Tuberculosis or other respiratory disease
Yes
No
Do you drink alcohol?
Yes
No
If so, how much?
Do you smoke?
Yes
No
If so, how much?
Hepatitis, jaundice, or liver trouble
Yes
No
Herpes or other STD
Yes
No
HIV-positive/AIDS
Yes
No
Glaucoma
Yes
No
Do you wear contact lenses?
Yes
No
History of head injury?
Yes
No
Epilepsy or other neurological disease?
Yes
No
History of alcohol or drug abuse?
Yes
No
Do you have any disease, condition, or problem not listed previously that you feel we should know about?
Yes
No
If so, please describe);
ARE YOU ALLERGIC, OR HAVE YOU REACTED ADVERSELY,TO ANY OF THE FOLLOWING?
Aspirin
Yes
No
Codeine
Yes
No
Dental Anesthetics
Yes
No
Erythromycin
Yes
No
Jewelry
Yes
No
Latex
Yes
No
Metals
Yes
No
Penicillin
Yes
No
Tetracycline
Yes
No
Sulfa
Yes
No
Other
DURING THE PAST 12 MONTHS, HAVE YOU TAKEN ANY OF THE FOLLOWING?
Antibiotics or sulfa drugs
Yes
No
Anticoagulants (e.g., Coumadin)
Yes
No
High blood pressure medicine
Yes
No
Tranquilizers
Yes
No
Insulin, Orinase, or similar drug
Yes
No
Aspirin
Yes
No
Digitalis or drugs for heart trouble
Yes
No
Nitroglycerin
Yes
No
Cortisone (steroids)
Yes
No
Natural remedies
Yes
No
Nonprescription drug/supplements
Yes
No
Other
WOMEN
Are you taking contraceptives or other hormones?
Yes
No
Are you pregnant?
Yes
No
If so, expected delivery date:
Are you nursing?
Yes
No
Have you reached menopause?
Yes
No
If so, do you have any symptoms?
List Medications You Are Taking:
Date:
Submit
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