Medical History Form
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1MEDICAL HISTORY
1.
GENERAL HEALTH (PLEASE CHECK ONE)
EXCELLENT( )
GOOD( )
FAIR( )
POOR( )
2.
HAS THERE BEEN ANY CHANGE IN YOUR GENERAL HEALTH WITHIN THE PAST YEAR? YES( )
NO( )
3.
YOUR PHYSICIAN’S NAME AND
ADDRESS__________________________________________________________________________________________
4.
YOUR LAST PHYSICAL EXAMINATION WAS ON:______________________________________________________
5.
ARE YOU CURRENTLY TAKING ANY MEDICATION? YES( ) NO( ) IF YES, FOR WHAT PURPOSE?________
__________________________LIST MEDICATIONS: _____________________________________________________
6.
DOES YOUR PHYSICIAN REQUIRE YOU TO HAVE ANTIBIOTICS PRIOR TO TREATMENT? YES( ) NO( )
7.
HAVE YOU EVER BEEN TREATED FOR ANY OF THE FOLLOWING?:
PLEASE CIRCLE YES OR NO
HEART DISEASE
YES
NO
STROKE
YES
NO
RHEUMATIC FEVER
YES
NO
GLAUCOMA
YES
NO
ABNORMAL BLOOD PRESSURE
YES
NO
FAINTING SPELLS
YES
NO
ULCERS
YES
NO
PERSISTENT DIARRHEA
YES
NO
TUBERCULOSIS/LUNG DISEASE
YES
NO
THYROID PROBLEMS
YES
NO
DIABETES
YES
NO
RESPIRATORY PROBLEMS
YES
NO
EPILEPSY
YES
NO
KIDNEY PROBLEMS
YES
NO
MITRAL VALVE PROLAPSE
YES
NO
CANCER
YES
NO
CONGENITAL HEART DISEASE
YES
NO
ABNORMAL BLEEDING
YES
NO
CARDIAC PACEMAKER
YES
NO
ANEMIA
YES
NO
ARTHRITIS
YES
NO
ARE YOU ALLERGIC TO ANY OF THE FOLLOWING?
AIDS OR HIV INFECTION
YES
NO
LOCAL ANESTHETICS
YES
NO
ANY COMMUNICABLE DISEASE YES
NO
PENICILLIN/ANTIBIOTICS
YES
NO
HEART MURMUR
YES
NO
SULFA DRUGS
YES
NO
JAUNDICE
YES
NO
BARBITURATES/SEDATIVES
YES
NO
ASTHMA OR HAY FEVER
YES
NO
ASPIRIN
YES
NO
SINUS TROUBLE
YES
NO
IODINE
YES
NO
PERSISTENT COUGH
YES
NO
CODEINE /NARCOTICS
YES
NO
HEPATITIS
YES
NO
LATEX
YES
NO
ARTIFICIAL JOINTS (hip, knee, etc) YES
NO
OTHER_______________
YES
NO
WOMEN
1. ARE YOU PREGNANT? IF SO, EXPECTED DELIVERY DATE_________________
YES
NO
2. DO YOU HAVE ANY PROBLEMS ASSOCIATED WITH YOUR MENSTRUAL PERIOD? YES
NO
3. ARE YOU NURSING?
YES
NO
4. ARE YOU TAKING BIRTH CONTROL PILLS?
YES
NO
THIS INFORMATION IS ACCURATE AND TRUE TO THE BEST OF MY KNOWLEDGE.
PATIENT SIGNATURE___________________________________________________ DATE__________________________
*Reviewed by Doctor prior to treatment.
DOCTOR SIGNATURE___________________________________________________ DATE__________________________
2
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