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:
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: ___________________________________________________________________ Have you ever had a serious injury to the head or neck? Discuss: ___________________________________________________________________ Have you ever had any other illness not listed above? Discuss: ___________________________________________________________________ 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.