Medical History Update

PATIENT NAME:

DOB:

FAMILY DOCTOR:

FAMILY DOCTOR PHONE:

IF CANCER - SPECIFY TYPE:

PLEASE LIST ALL PRESCRIPTION AND OVER THE COUNTER MEDICATIONS WHICH ARE CURRENTLY TAKING:

Add prescription/over the counter medication

HAVE YOU HAD ANY MAJOR SURGERIES?

YES NO

IF YES, PLEASE EXPLAIN:

DO YOU HAVE HEALTH PROBLEMS OR DISEASES NOT LISTED ABOVE OR THAT NEED FURTHER CLARIFICATIONS?

YES NO

IF YES, PLEASE EXPLAIN:

ARE YOU CURRENTLY TAKING BLEOMYCIN (CANCER MEDICATION)?

YES NO

IS THERE ANY ALERGIES TO PENICILLIN OR OTHER DRUGS?

YES NO

IF YES, WHICH DRUGS/MEDICATIONS:

DO YOU HAVE ANY EMOTIONAL/PSYCHOLOGICAL PROBLEMS?

YES NO

IF YES, PLEASE EXPLAIN:

PLEASE DESCRIBE ANY CURRENT MEDICAL TREATMENT INCLUDING PENDING SURGERY, RECENT INJURIES OR ANY OTHER INFORAMION THAT OUR OFFICE SHOULD BE AWARE OF AT THIS TIME:

WOMEN:

ARE YOU CURRENTLY PREGNANT?

YES NO

DUE DATE:

BIRTH CONTROL?

YES NO

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PATIENT/PARENT/GUARDIAN NAME:

DATE:

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