Medical History Form

Last, First, Middle

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:

Call (719) 123-4567

840 Newport Center Dr #100, Newport Beach, CA 92660

(719) 123-4567

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