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Medical History

Are you allergic to any of the following?


Latex gloves:
Penicillin:
Codeine:
Aspirin:
List all other allergies:
Are you or have you taken any of the following medications and if so, how long?
Fosamax:
Actonel:
Boniva:
Aredia:
Zometa:
Reclast:
Are you or have you taken any of the following (blood thinner) medications, and if
so, how long?
Vitamin E:
Aspirin:
Plavix (clopidogrel)
Coumadin (warfarin):
Persantine (dipyridamole):
Lovenox (enoxaparin):

List all medications (include over the counter) that you are currently taking:

Medication: For what condition:

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Please circle all that apply to you, presently or previously:
Heart valve replacement Bacterial Endocarditis Heart Pace maker
Mitral valve prolapse Rheumatic fever Artificial joints
Heart Surgery Angina Heart attack
Heart Murmur Blood Pressure H/L Stroke
Anemia Excessive bleeding Blood transfusion
Emphysema Tuberculosis Asthma
Sinus Trouble Cancer Radiation therapy
Chemotherapy Kidney problems Dialysis
Ulcer Intestinal disease Thyroid disease
Diabetes: I or II Hypoglycemia Liver disease
Hepatitis Arthritis Jaw pain
Herpes HIV/AIDS Psychiatric care
Fainting/Dizziness HX-Alcohol abuse HX-Drug abuse
Smoker

Have you been hospitalized in the past 5 years or had major surgery? Discuss:
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Have you ever had a serious injury to the head or neck? Discuss:
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Have you ever had any other illness not listed above? Discuss:
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Physicians Name:___________________________Number:__________________
Pharmacys Name:__________________________Number:__________________

Female patients:
Are you pregnant?
Trying to get pregnant?
Nursing?
Taking birth control?
To the best of my knowledge, all of the preceding answers are correct. If I have
any changes in my health status or if my medications change, I shall inform the
office.

Patient Signature:_______________________________________Date:_________