• Medical History

  • Birth Date *
     - -
    2 digit month, 2 digit day, 4 digit year
  •  -
  •  -

  • Do you have or ever had any of the following?

  • High Blood Pressure*
  • Low Blood Pressure*
  • Heart Disease: Atrial fib, Vent fib, CHF*
  • Congenital Heart Disease*
  • Artificial Heart Valve, Unrepaired heart defect*
  • History of Infective Endocarditis*
  • Angina*
  • Heart Surgery*
  • Heart Attack*
  • Stroke*
  • Pacemaker, Implantable defibrillator*
  • High Cholesterol*
  • Anemia/Blood Disorder*
  • Excessive Bleeding/ Blood Thinners
  • Emphysema, C.O.P.D.*
  • Tuberculosis*
  • Asthma*
  • *
  • Hay Fever*
  • *
  • Sleep apnea*
  • Kidney Disease*
  • Liver Disease*
  • Hepatitis*
  • *
  • Diabetes*
  • Acid Reflux Disease*
  • Intestinal Problems, Stomach Ulcers, Celiac*
  • Thyroid Problem*
  • *
  • Hormone Deficiency*
  • Autoimmune Disorders: Fibromyalgia, Crohn’s, MS*
  • Arthritis*
  • *
  • Epilepsy/Convulsions*
  • Neurologic Problems : ADHD, Autism*
  • Glaucoma*
  • Cancer*
  • Treatment*
  • Joint Replacement:*
  • *
  • Viral infections, Cold Sores*
  • HIV/ AIDS*
  • Osteoporosis, Osteopenia (Bisphosphonates)*
  • Alcoholism, Drug dependency, Medical Marijuana*
  • Birth Control Pill, ,*
  • Pregnant*
  • Breastfeeding*
  • Male: Prostate disorders*

  • Are you allergic to or had a bad reaction to any of the following

  • Amoxicillin, Penicillin*
  • Erythromycin*
  • Clindamycin*
  • Sulfa*
  • Tetracycline, Doxycycline*
  • Local Anaesthetic*
  • Epinephrine*
  • Chlorhexidine*
  • Fluoride*
  • Red Dye*
  • Ibuprofen, Toradol, NSAIDS*
  • Tylenol*
  • Aspirin*
  • Codeine, Morphine*
  • Latex, Band-aids*
  • Metals*
  • Nuts*
  • Milk, Casein protein*
  • Fruits*
  • Other*
  • Are there any conditions or diseases not listed above that you currently have or had in the past?*
  • Have you ever been hospitalized or had surgery?*

  • Medication List

  • Are you taking any medication?*
  • Please list all medications you are taking and the reason for taking them. ( Click on + to add more )*
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: