Adult Medical History
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1
2Adult Medical History
Patient Name
D.O.B.
Emergency Contact (Name/Phone Number) _____________________________________________________
Medical History
1. Physician
Address
2.When was your last physical examination?
3. Are you under the care of a physician?..............................................................................................
Yes
No
If yes, for what reason(s)?
4. Are you presently taking any medications/drugs/pills/herbals/supplements?........................................
Yes
No
If yes, please list:
5. (Women) Is there a chance you are pregnant? …………………………………………………………………
Yes
No
If yes, anticipated due date?__________________________________________________________________________
6. Do you take oral contraceptives? ……………………………………………………………………….
Yes
No
7. Are you allergic/sensitive to:
None
Codeine
Penicillin
Local Anesthetic
Latex
Pine Nuts
Dyes
Other_______________________________________________________________________________________
8. Do you smoke, chew or use E -cigarettes? …………………………………………………………………………
………………………
. Yes
No
If yes, please indicate which one(s), daily frequency and how long? _____________________________________________
9. Do you have Diabetes? ............................................................................................................................
Yes
No
If Yes, please indicate ……….
Type 1
Type 2
Last HbA1c date and level_________________________
10. Do you have, or have you ever had:
Excessive or prolonged bleeding ..................
Yes
No
Heart trouble .........................................
Yes
No
yroid problem .................................................
Yes
No
Heart murmur.........................................
Yes
No
Jaundice .....................................................................
Yes
No
Heart surgery .........................................
Yes
No
Hepatitis(Type).................................................
Yes
No
Heart pacemaker .....................................
Yes
No
Cancer ......................................................................
Yes
No
Rheumatic fever ....................................
Yes
No
Chemotherapy/radiation .....................................
Yes
No
Congenital heart defects ......................
Yes
No
Arthritis ...............................................................
Yes
No
Arti cial heart valve/stent/gra .............
Yes
No
Arti cial joint replacements ................................
Yes
No
Abnormal blood pressure ....................
Yes
No
Cortico-Steroid treatment .....................................
Yes
No
Stroke………………………….…….
Yes
No
Osteoporosis/treatment w/ Bisphosphonates ...
Yes
No
Ulcers / GERD ..........................................
Yes
No
HIV positive/AIDS .............................................
Yes
No
Kidney trouble/Dialysis .........................
Yes
No
Oral herpetic lesions .............................................
Yes
No
Tuberculosis or lung disease ................
Yes
No
Sexually Transmitted disease ..................................
Yes
No
Asthma………………………...…… .
Yes
No
Psychiatric care ........................................................
Yes
No
Sinus trouble ..............................................
Yes
No
Glaucoma ................................................................
Yes
No
Hearing impaired ..................................................
Yes
No
Epilepsy / seizures .................................
Yes
No
Chemical dependency…………………….... .
Yes
No
Fainting spells ..........................................
Yes
No
Do you take pre-medication for anything........
Yes
No
Yes
No
Anemia .................................................
..
If you pre-medicate for what ___________________________
Leukemia ...........................................................
Yes
No
11. Have you had any other serious illness, hospitalization or accident?
Yes
No
If yes, please explain:_______________________________________________________________________
(OVER PLEASE)
Rev 2/15
102503_3117731-00100_CP_85x11-CTR_J.indd 1
10/16/2015 2:57:14 PM
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