Confidential Medical History Form Page 2
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1
2Have you ever had any of the following medical conditions? (Check YES or NO):
YES
NO
YES
NO
YES
NO
(
)
(
) Anemia
(
)
(
) Cancer
(
)
(
) Chest Pain/Angina/MVP
(
)
(
) Diabetes
(
)
(
) Asthma/Wheezing
(
)
(
) Dizziness/Fainting Spells
(
)
(
) Kidney Trouble
(
)
(
) Shortness of Breath
(
)
(
) Bleeding Disorder/ Bruising
(
)
(
) Thyroid Trouble (
)
(
) High Blood Pressure (
)
(
) Blood Clot in Vein
(
)
(
) Liver Disease
(
)
(
) Hepatitis/Jaundice
(
)
(
) Epilepsy/Convulsions/Seizures
(
)
(
) Varicose Veins
(
)
(
) Strokes/Paralysis
(
)
(
) Rheumatic fever
(
)
(
) HIV/AIDS
(
)
(
) Depression/Anxiety
(
)
(
) Recent Bladder Infection
(
)
(
) Unconsciousness (
)
(
) Psychiatric Treatment (
)
(
) Headaches
Notes:
Does anyone in your direct family have any of the above medical conditions?
Do you take any medication? If yes, what kind?
NAME
DOSAGE
LAST TAKEN
Have you taken any of the following medication in the last six months?
YES
NO
Cortisone, Prednisone or other steroids—if yes, how long ago?
Aspirin (this does NOT include Advil, Aleve, Ibuprofen, Motrin)
Anticoagulants--Coumadin, Heparin
Antidepressants/Sleep Aids (Prozac, Zoloft, Xanax or other)
Addiction to any drug, narcotic or medication—if yes, what?
Are you allergic to any drugs, food or medication? If yes, what kind of reaction?
YES
NO
YES
NO
Ibuprofen
Penicillin, Doxycycline, or other antibiotics
Iodine/ Shellfish
Novocaine, Lidocaine or other anesthetics
Latex
Food Allergy
Adhesive tape
Medicine Allergy:
I have honestly and completely disclosed my medical history, including allergies, medications taken, and
reactions I have had to anesthetics and drugs. I consent to my physician relying on this disclosure to be
complete. I assume all responsibility for any problems or complications arising as a result of my neglecting to
disclose any pertinent history.
Patient Signature:
______________________________
Date:
Medical History Reviewed By:
________________ Date: ___________________
Rev 7/10
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