Patient Medical History

Patient Name

Date of Birth

Today's Date

A thorough medical history is an important part of your record. Please answer all questions accurately because it will allow us to provide you the best possible treatment from a fully informed health professional. If you don’t know, or do not understand the question please leave blank.

1. Are you in good health?

Yes No

2. Has there been any change in your general health within the past year?

Yes No

3. Date of last medical examination

4. Are you now under the care of a physician?

Yes No

Name and address of physician

5. Have you ever been hospitalized for any serious illness or operation?

Yes No

If Yes, please explain

6. Do you (presently) have a cough, chest or head cold or sore throat

Yes No

7. Do you (presently) have any lip sores?

Yes No

8. Do you have any of the following?

Allergies

Asthma or hay fever

Hives or skin rash

9. Do you have Diabetes?

Yes, have Diabetes

Do you have to urinate (pass water) more than 6 times per day?

Are you thirsty much of the time?

Does your mouth frequently become dry?

Have any blood relatives had Diabetes?

12. Do you have arthritis?

Yes, have arthritis

Inflammatory rheumatism (painful swollen joints)

Joint replacement

If joint replacement, what date?

13. Have you had (do you have) a sexually transmitted disease?

gonorrhea

syphilis

herpes

HIV

Do you have a bleeding disorder?

Hemophiliac

Have or had abnormal bleeding associated with previous surgery or trauma

Bruise easily

Have a blood disorder such as anemia (thin blood)

Have required a blood transfusion

If you had blood transfusion, please explain circumstances

If you have had surgery, chemotherapy or X-ray treatment for a tumor, growth or other condition, please explain

Other Drugs Taken?

Have you ever taken any of the following prescription medication for weight reduction (diet pills)?

Fen-Phen (fenfluramine + phentermine)

Pondimin (fenfluramine)

Redux (dexfenfluramine)

If you have ever taken any of the above drugs, have you had a medical exam to insure that your heart valves were not affected?

Are you taking or have you taken cortisone or steroids within the last 2 years?

Are you allergic or have you reacted adversely to:

Local anesthetics

Penicillin or other antibiotics

Barbiturates, sedatives, or sleeping pills

Aspirin

Iodine

Codeine or other narcotics

Metals

Latex

Other Adverse Reactions:

I am a smoker

I use smokeless tobacco

How much alcohol do you consume per day?

Have been in a drug or substance rehabilitation program

Am wearing contact lenses

Am Pregnant

Do you have any disease, condition, or problem not listed above? If so, please explain

This information will only be used to determine financial eligibility and/or provide medical or dental treatment at the Clinic.

By checking this box I give my consent for this information to be used for this purpose.

I certify that the information above is accurate to the best of my knowledge.

Date Submitted

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