PATIENT MEDICAL HISTORY
Physician
Office Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Date of last physical exam
-
Month
-
Day
Year
Date
Are you under medical treatment now?
Yes
No
Are you under medical treatment now?
Yes
No
Have you ever been hospitalized for any surgery or serious illness?
Yes
No
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Do you have or have you had any of the following conditions? Please check all that apply.
Heart Attack/Surgery
Heart Murmur
Heart disease/Pacemaker
Chest Pains
High/Low Blood Pressure
Rheumatic Fever
Stroke
Asthma/Respiratory
Hay Fever/Allergies
Full/Partial Joint Replacement
Hepatitis/Jaundice
Kidney Disease
Diabetes
Thyroid Problems
Stomach Problems
Leukemia/Anemia/blood disorder
Cancer
Radiation/Chemotherapy
Osteoporosis Treatment
Arthritis
Glaucoma
Fainting
Epilepsy/Convulsions
HIV Infection/Aids
Herpes Simplex I or II
Drug Addiction
I have taken Fen-Phen
Do you wear contacts
Any other conditions not listed above?
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Do you snore or have you been told you snore?
Yes
No
Have you had a sleep study or been told to get one?
Yes
No
Do you wear a CPAP or have been told you need one?
Yes
No
Please list any disease, condition or problem not listed.
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WOMEN ONLY
Are you pregnant?
Yes
No
Are you taking birth control?
Yes
No
ARE you aware that antibiotics can decrease the effectiveness of birth control?
Yes
No
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MEDICATIONS
Currently taking any medications?
Yes
No
If yes, please list medications you are currently taking.
Pharmacy Name
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ALLERGIES
Have you had reaction to any of the following? (please check if yes)
Aspirin/Ibuprofen
Codeine
Iodine
Latex
Penicillin
Sedatives
Sulfa
Local Anesthetic
No known drug allergies
Any other allergies not listed above?
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Signature: I certify that I have read and understand the above information. To the best of my knowledge,the above questions have been accurately answered. I understand that providing incorrect information maybe detrimental to my health.
Patient
Parent or Guardian
Date
-
Month
-
Day
Year
Date
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