Medical History
Patient Name
*
First Name
Last Name
Are you under a physicians care?
Yes
No
Who is your general physician?
Have you ever been hospitalized or had a major operation?
Yes
No
Please Explain
Have you ever had a serious injury to your head or neck?
Yes
No
Please Explain
Are you on a special diet?
Yes
No
Please list any medications or supplements you are taking
Please list any allergies to medications or substances
FOR WOMEN: Please check
Pregnant/Trying to get pregnant
Nursing
Taking contraceptives
Do you now have or have you ever had any of the following?
Heart murmur or defect
Emphysema
Kidney disease
Angina chest pain
COPD
Dialysis
Heart Attack
Tuberculosis
Thyroid disease
Congenital heart disorder
Asthma
Parathyroid disease
Mitral Valve Prolapse
Seasonal Allergies
Arthritis
Scarlet Fever
Cancer
Artificial joint
Artificial Heart Valve
Tumors/growths
Cortisone Medication
Coronary shunts or stints
Radiation Treatment
Stroke
Pacemaker
Chemotherapy
Epilepsy/seizures
Bacterial Endocarditis
Osteoporosis
Fainting/dizziness
Anemia blood disorder
Stomach/intestinal disease
Psychiatric care
Bruise easily
Ulcers
Alzheimer's disease
High blood pressure
Low blood pressure
Recent weight loss
Sexually transmitted disease
Blood disorder
Liver disease
Cold sores
Leukemia
Hepatitis A
Hepatitis B
Hepatitis C
HIV/AIDS
Blood transfusion
Diabetes
Drug/alcohol addiction
Swelling of limbs
Hypoglycemia
Gout
Lung disease
Excessive thirst
Allergies
Pulmonary shunt
Night sweats
Hives/rash
Breathing problem
Sleep apnea
Cochlear implants
Frequent cough
Dental premedication
Please explain if you have any of the conditions above
Patient Signature (Parent or Guardian if minor)
*
Clear
Date
-
Month
-
Day
Year
Date
Please verify that you are human
*
Submit
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