• PATIENT HISTORY

  • Date
     - -
  • Date of last physical examination
     - -

  • General Health

  • Are you currently taking any medications?
  • Check all that apply:
  • Have you ever been hospitalized?
  • Have you ever had surgery (including dental)?
  • Do you have diabetes?
  • Diabetes in family?
  • Do you get frequent leg cramps or numbness in your feet/toes?
  • Do you smoke?
  • Do you consume alcoholic beverages?
  • If a woman, are you, to your knowledge, pregnant?

  • Allergies: Are you allergic or sensitive to any of the following?

  • Penicillin
  • Other antibiotics
  • Novocaine or other local anesthetics
  • Codeine
  • Aspirin
  • Iodine
  • Foods
  • Adhesive tapes
  • Tranquilizers or sleeping pills
  • Other

  • Have you or a family member ever had any of the following conditions?
    (Check where appropriate & please explain)

  • Rows
  • Should be Empty: