Medications That Cause Allergic Reactions List

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List any medications which have caused an allergic reaction
Y
N
Antibiotics
Y
N
Metals
Other allergens:
Y
N
Aspirin
Y
N
Penicillin
_____________________________
_____________________________
Y
N
Barbiturates
Y
N
Plastic
_____________________________
Y
N
Codeine
Y
N
Sedatives
_____________________________
Y
N
Latex
Y
N
Sleeping pills
Y
N
Local anesthetics
Y
N
Sulfa drugs
_____________________________
List any medications you are currently taking
Y
N
Antacids
Y
N
Codeine
Y
N
Pain Medication
Y
N
Antibiotics
Y
N
Cortisone
Y
N
Sleeping Pills
Y
N
Anticoagulants
Y
N
Diet Pills
Y
N
Sulfa Drugs
Antidepressants
Y
N
Y
N
Heart Medication
Y
N
Tranquilizers
Y
N
Anti-inflammatory drugs
Y
N
High Blood Pressure Medication
(non-steroid)
Y
N
Insulin
Other current medications:
Y
N
Barbiturates
Y
N
Muscle Relaxants
_________________________
Y
N
Blood thinners
Y
N
Nerve Pills
_________________________
Medical History
Y
N
Anemia
Y
N
Heart pacemaker
Y
N
Prior orthodontic
treatment
Heart valve replacement
Y
N
Arteriosclerosis
Y
N
Y
N
Asthma
Y
N
Heartburn or a sour taste
Y
N
Recent excessive
in the mouth at night
weight gain
Y
N
Autoimmune Disorders
Y
N
Bleeding easily
Y
N
Hepatitis
Y
N
Rheumatic fever
Y
N
Chronic sinus problems
Y
N
High blood pressure
Y
N
Shortness of breath
Swollen, stiff or
Y
N
Chronic fatigue
Y
N
Immune system
Y
N
painful joints
disorder
Y
N
Congestive heart failure
Y
N
Injury to:
Y
N
Current pregnancy
Face Neck Head
Y
N
Thyroid problems
Y
N
Diabetes
Neck
Teeth
Y
N
Tonsillectomy
Wisdom teeth
Y
N
Dizziness
Y
N
Insomnia
Y
N
extraction
Y
N
Emphysema
Y
N
Irregular heart beat
Y
N
Epilepsy
Y
N
Jaw joint surgery
Y
N
Fibromyalgia
Y
N
Low blood pressure
Y
N
Frequent sore
Y
N
Memory loss
Other medical history:
throats
______________________________
Y
N
Gastroesophageal
Y
N
Migraines
______________________________
Reflux Disease
______________________________
(GERD)
______________________________
Y
N
Hay fever
Y
N
Morning dry mouth
Y
N
Heart disorder
Y
N
Muscle spasms or
cramps
Needing extra pillows to
Y
N
Heart murmur
Y
N
help breathing at night
Heart pounding
Y
N
Y
N
Nighttime sweating
or beating
irregularly during
the night
Y
N
Osteoarthritis
Y
N
Osteoporosis
Y
N
Poor Circulation
Patient Signature:_____________________________________________________________ Date: _________________

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