Patient Information
All information is CONFIDENTIAL. Fields marked with a * are required
Today's Date
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Year
2 digit month, 2 digit day, 4 digit year
Patient Name
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First Name
Middle Name
Last Name
Patient Address
Street Address
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City
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South Carolina
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Tennessee
Texas
Utah
Vermont
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State
Zip Code
Home phone
Format: (000) 000-0000.
Cell phone
Format: (000) 000-0000.
Patient Email address
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Patient Medical History Update
Physician
Physician's Office phone
Format: (000) 000-0000.
Date of last exam
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Month
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Day
Year
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Please select Yes or No to indicate if you have had any of the following:
Rows
Yes
No
1. Are you under medical treatment now?
2. Do you use controlled substances?
3. Have you ever been hospitalized for any surgical operation or serious illness within the last 5 years?
4. Are you taking any medication(s) including non-prescription medicine?
5. Have you ever taken Fern-Phen/Redux?
6. Do you use tobacco?
7. Have you ever taken Fosamax, Boniva, Actonel or any cancer medications containing bisphosphonates?
8. Have you taken Viagra, Revatio, Cialis or Levitra in the last 24 hours?
9. Do you have a persistent cough or throat clearing not associated with a known illness (lasting more than 3 weeks)?
If you answered YES to question #3 above (surgical operation or serious illness), please explain:
If you answered YES to question #4 above (taking medications), please explain:
Do you have or have had any of the following?
Rows
Yes
No
High Blood Pressure
Heart Attack
Rheumatic Fever
Swollen Ankles
Fainting/ Seizures
Asthma
Low Blood Pressure
Epilepsy/ Convulsions
Leukemia
Diabetes
Kidney Diseases
AIDS/ HIV infection
Thyroid Problem
Heart Disease
Cardiac Pacemaker
Heart Murmur
Angina
Emphysema
Cancer
Arthritis
Hepatitis/ Jaundice
Chest Pains
Easily Winded
Stroke
Hay Fever/ Allergies
Tuberculosis
Radiation Therapy
Glaucoma
Recent Weight Loss
Liver Disease
Valve Replacement
Respiratory Problems
Mitral Valve Prolapse
Anemia
Frequently Tired
Stomach Troubles / Ulcers
Joint Replacement / Implant
Sexually Transmitted Disease
Do you have any other health problem not listed above?
Are you allergic to any of the following?
Rows
Yes
No
Local Anesthetics (e.g. Novocain)
Penicillin or any other Antibiotics
Sulfa Drugs
Barbiturates
Sedatives
Iodine
Aspirin
Any Metals
Latex Rubber
Are you allergic to any other not listed above?
(WOMEN ONLY) Please answer:
Rows
Yes
No
Are you pregnant or think you may be pregnant?
Are you nursing?
Are you taking oral contraceptives?
Medical changes:
Current medications:
Signature of patient (or parent/guardian if minor)
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