Medical History Form

Medical History

What is your estimate of your general health?

Do You Have or Have You Ever Had:

hospitalization for illness or injury
an allergic reaction to aspirin, ibuprofen, acetaminophen, codeine
an allergic reaction to penicillin
an allergic reaction to erythromycin
an allergic reaction to tetracycline
an allergic reaction to sulpha
an allergic reaction to local anesthetic
an allergic reaction to fluoride
an allergic reaction to metals (nickel, gold, silver)
an allergic reaction to latex
an allergic reaction to other
heart problems or cardiac stent in last six months
history of infective endocarditis
artificial heart valve or repaired heart defect (PFO)
pacemaker or implantable defibrillator
artificial prosthesis (heart valve or joints)
rheumatic or scarlet fever
high or low blood pressure
a stroke (taking blood thinners)
anemia or other blood disorder
prolonged bleeding due to a slight cut (INR>3.5)
emphysema or sarcoidosis
tuberculosis
asthma
breathing or sleeping problems (snoring or sinus)
kidney disease
liver disease
jaundice
thyroid, parathyroid disease or calcium deficiency
hormone deficiency
high cholesterol or taking statin drugs
diabetes (HbA1c)
stomach or duodenal ulcer
digestive disorders (gastric reflux)

Do You Have or Have You Ever Had: Continued.

osteoporosis/osteopenia (taking bisphosphonates)
arthritis
glaucoma
contact lenses
head or neck injuries
epilepsy or convulsions (seizures)
neurologic problems (ADD)
viral infections and cold sores
any lumps or swelling in the mouth
hives, skin rash or hay fever
venereal disease
hepatitis
HIV/AIDS
tumor or abnormal growth
radiation therapy
chemotherapy
emotional problems
psychiatric treatment
antidepressant medication
alcohol/drug dependency

Are You:

presently being treated for any other illness
aware of a change in your general health
taking medication for weight management
taking dietary supplements
often exhausted or fatigued
subject to frequent headaches
a smoker or smoked previously
often unhappy or depressed
FEMALE-taking birth control pills
FEMALE-pregnant
MALE-prostate disorders

Medication Treatment History

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