Patient Medical History First Name *Last Name *Street Address *Apartment, suite, etcCity *State/Province *Postal Code *Date of Birth *Phone *CellWorkEmergency Contact Name *Emergency Contact Number *Have there been any changes in your general health in the past year? *YesNoUnsureIf yes, please explain *Are you currently taking any medications, non-prescription drugs, or herbal supplements of any kind? *YesNoIf yes, please list them *Do you have any allergies? (List Below) Medications: Latex/Rubber products Other: (Foods, Hay fever) Have you ever had an adverse reaction to any medication or injections? *YesNoUnsureIf yes, please list *Do you have asthma? *YesNoUnsureIf yes, which inhaler do you use? *Do you have, or have you ever had, any heart or blood pressure problems? *YesNoUnsureIf yes, please list *Do you have, or have you ever had, a replacement or repair of a heart valve, an infection of the heart, or a heart condition from birth? *YesNoUnsureHave you ever had Hepatitis, jaundice, or liver disease? *YesNoUnsureIf yes, which type of Hepatitis? *Do you have a prosthetic or artificial joint? *YesNoUnsureIf yes, please explain *Do you have bleeding problems or a bleeding disorder? *YesNoUnsureIf yes, please explain *Have you ever been hospitalized for any illness or surgery? *YesNoIf yes, please explain *Do you have any conditions or therapies that could affect your immune system (e.g., leukemia, AIDS, chemotherapy)? *YesNoUnsureIf yes, please explain *Do you have any of the following?Emphysema EpilepsySeizuresFibromyalgiaThyroid DisorderHead/Neck InjuryKidney DiseaseLung DiseaseLupusMigraineOsteoporosisMedications (e.g. Fosamax, Actonel)PacemakerHigh/Low Blood PressureDiabetes Type 1 Diabetes Type 2 Drug /Alcohol DependencyTypeHypo/HyperglycemiaRadiation/ChemotherapyRheumatic FeverSexually/ Transmitted InfectionCold SoresAlzheimersAnginaAnemiaArthritisBlood TransfusionCancerChest PainEmphysemaHeart MurmurHodgkins DiseaseParkinsons DiseaseStomach UlcersThrustTmjTuberculosisNone of the aboveAre there any conditions or diseases not listed above that you have or have had?If yes, please explainAre there any medical conditions that run in your family (e.g., cancer, diabetes)? *YesNoUnsureIf yes, please specify. *Do you smoke or chew tobacco products? *YesNoDo you smoke or chew tobacco products? *YesNoUnsureFirst Name *Last NameDate *SignatureStart signing your signature here *Sign hereYour browser does not support e-Signature field.Submit
