Medical History

Name *
Name
Birth Date *
Birth Date
Today's Date *
Today's Date
Are you under a physcian's care now? *
Have you ever been hospitalized or had a major operation? *
Have you ever had serious head or neck injury? *
Are you taking any medications, pills, or drugs? *
Do you take, or have you taken, Phen-fen or Redux? *
Have you ever taken Fosamax, Boniva, Actonel or any other medication containing bisphosphates? *
Are you on a special diet? *
Do you use tobacco?
Women: Are you...
Are you allergic to any of the following?
Do you use controlled substances?
Do you have, or have had any of the following?
AIDS/HIV Positive *
Alzheimer's Disease *
Anaphylaxis *
Anemia *
Angina *
Arthritis/Gout *
Artificial Heart Valve *
Artificial Joint *
Asthma *
Blood Disease *
Blood Transfusion *
Breathing Problems *
Bruise Easily *
Cortisone Medicine *
Diabetes *
Drug Addiction *
Easily Winded *
Emphysema *
Epilepsy or Seizures *
Excessive Bleeding *
Excessive Thirst *
Fainting Spells/Dizziness *
Frequent Cough *
Frequent Diarrhea *
Frequent Headaches *
Genital Herpes *
Hemophilia *
Hepatitis A *
Hepatitis B or C *
Herpes *
High Blood Pressure *
High Cholesterol *
Hives or Rash *
Hypoglycemia *
Irregular Heartbeat *
Kidney Problems *
Leukemia *
Liver Disease *
Low Blood Pressure *
Radiation Treatments *
Recent Weight Loss *
Renal Dialysis *
Rheumatic Fever *
Rheumatism *
Scarlet Fever *
Shingles *
Sickle Cell Disease *
Sinus Trouble *
Spina Bifida *
Stomach/Intestinal Disease *
Stroke *
Swelling of Limbs *
Thyroid Disease *
Tonsilitis *
Tuberculosis *
Tumors or Growths *
Ulcers *
Venereal Disease *
Yellow Jaundice *
Have you had any serious illness not listed? *
To the best of my knowledge the questions on this form have been accurately answered.I understand that providing inaccurate information can be dangerous to my (or patient's health) I understand it is my responsibility to inform the office of any changes to my medical status. *
To the best of my knowledge the questions on this form have been accurately answered.I understand that providing inaccurate information can be dangerous to my (or patient's health) I understand it is my responsibility to inform the office of any changes to my medical status.
Today's Date *
Today's Date