Medical Health HistoryPatient Last Name:Birth DateAddress:City:State:Zip Code:First NameE-Mail:Home Phone:Cell Phone:Please answer the following questions:1. Are you under a physician`s care now?YesNoIf yes, please explain:7. Do you use Tobacco?YesNoIf yes, please explain:8. Do you use controlled substances?YesNoIf yes, please explain:9. Are you taking blood thinner?YesNoIf yes, please explain:WOMEN ARE YOU:Pregnant/Trying to get pregnant?YesNoAre you Nursing?YesNoTaking Birth Control?YesNoAre you taking any medications, pills, or drugs?
If yes, please provide names of medication/s below, or attach medications list.Yes6. Are you on a special diet?Do you have any allergies to:YesIf yes, please explain:2. Have you ever been hospitalized/surgery?NoIf yes, please explain:3. Have you had a serious head or neck injury?YesNoIf yes, please explain:4. Have you ever taken Phen-Fen or Redux?YesNoNoIf yes, please explain:5. Have you taken Fosamax, Boniva, Actonel or any other Bisphosphonate (osteoporosis meds or cancer treatment medications?Arthritis/GoutAnemiaAnaphylaxisAlzheimer`s DiseaseHIV/AIDS PositiveDo you have, or have you had, and of the following: (please place a check mark on yes or no)PenicillinAnginaCold Sores/
Fever BlisterChemotherapyCancerBruise EasilyBreathing ProblemsBlood TransfusionBlood DiseaseAsthmaArtificial Heart ValveChest PainsDiabetesHeart Disorder
from birthCortisone Medicine
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Excessive ThirstExcessive BleedingEpilepsy/SeizuresEmhysemaEasily WindedPlease List Any Other Medical Conditions Not Listed AboveNoYesYesYesYesYesYesYesYesYesNoYesYesYesYesYesYesYesNoYesYesYesYesYesYesYesYesNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoYesFainting SpellsFrequent CoughFrequent DiarrheaDizzinessFrequent HeadachesPacemakerHemophilia/Blood DisorderHeart Attack/FailureHeart DiseaseHeart MurmurGlaucomaHay FeverYesLung DiseaseKidney DialysisYesHigh CholesterolYesYesYesHives or RashYesIrregular HeartbeatYesYesYesYesLow Blood PressureNoYesOsteoporosisYesNoNoNoHepatitis AYesHigh Blood PressureYesNoMitral Valve ProlapseYesYesNoYesNoYesYesHypoglycemia (low sugar)YesYesYesKidney ProblemsYesYesYesLeukemiaHepatitis B or CLiver DiseaseYesNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoYesYesYesUlcersYesIntestinal DiseaseYesRheumatic FeverSwelling of LimbsTumors or growthsThyroid DiseaseYesPain in Jaw JointsYesYesYesShinglesVenereal DiseaseYesLymes DiseaseSickle Cell DiseaseYesYesYesUnexplained Weight LossYesYesYellow JaundicePsychiatric CareSinus TroubleYesYesRadiation TreatmentsSpina BifidaYesScarlet FeverYesYesYesStrokeTonsillitisParathyroid DiseaseYesNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNo1.YesNo1.TetracyclineLatexAspirinErythromycinCodeineJewelry/MetalsDental Anesthetic9.2.6.3.8.7.4.5.12.2.10.4.11.3.Signature: