Medical History
Full Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birthdate
*
-
Month
-
Day
Year
Date
Reason for visit (please be as specific as possible)
*
How did you find Dr. Liotta? Who may we thank for referring you?
Check any conditions that apply to you
*
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
Epilepsy
Heart arrhythmia
History of problems with anesthesia
History of autoimmune disease
None
Check any conditions that apply to any members of your immediate relatives:
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
Epilepsy
Heart arrhythmia
History of problems with anesthesia
History of autoimmune disease
Are you currently taking any medication?
*
Yes
No
If yes, please list your medications
Are you currently taking, or have you in the past taken, Accutane for any reason?
*
Yes
No
If yes, please describe your history with this Accutane.
Do you have any medication allergies?
*
Yes
No
Allergy to Latex
Allergy to local anesthesia
If yes, please list any medications you are allergic to
List any surgeries you have had in the past
Do you use or do you have history of using tobacco?
*
Yes
No
If you responded yes, please explain
Do you use or do you have history of using illegal drugs?
*
Yes
No
If you responded yes, please explain
How often do you consume alcohol?
*
Daily
Weekly
Monthly
Occasionally
Never
Signature
Clear
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