Name: ____________________________________
DOB: ___________________
MR# ___________________________
MEDICAL HISTORY
Are you currently being treated by a doctor? Yes___
No ___ If so, why? __________________________________________
Physician’s Name: ______________________ Physician’s Phone:_________________ Last Physical/Health Check: __________
List ALL medications and dosages (prescription, vitamins, herbs, and over-the-counter medications) ______________________
_______________________________________________________________________________________________________
Are you aware of any allergies to any of these:
Penicillin
Amoxicillin
Erythromycin
Y N
Y N
Y N
Dental Anesthetic
Sulfa
Codeine
Y N
Y N
Y N
Aspirin
Augmentin
Latex
Y
Y
Y
N
N
N
Any other allergies/drug allergies we should know about: ________________________________________________________
Have you ever had any of these health problems?
Asthma
Bleeding Problems
Blood Disorders
Blood Transfusions
Cancer
Diabetes
Epilepsy
Fainting Spells
Heart Condition
Heart Valve Problems
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
Heart Murmur
Pacemaker
Are You Pregnant?
Hearing Loss/Impairment
High Blood Pressure
Hepatitis
HIV/AIDS
Artificial Joints
Joint Disease
Kidney Disease
Liver Disease
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
Psychiatric Problems
Sickle Cell Anemia
Stroke
Shortness of Breath
Pain in Chest Upon Exertion
Rheumatic Fever
Tuberculosis
Thyroid Problems
Radiation Therapy
Drug Addiction
Alcoholism
Do you smoke or use other tobacco products? Yes ___ No ___
If so, how many cigarettes per day? ______ Number of years smoking _____
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
MEDICAL ALERT (for staff use)
Please explain all “Yes” answers and list any medical health problems not listed above:
_____________________________________________________________________
I have answered all the questions correctly to the best of my knowledge.
_______________________________ ________________
Patient Signature
Date
________________________________ _____________
Physician Signature
Date
______________
Date
______________________
Patient Signature
______________________
Physician/Hyg. Signature
Medical Changes _________________________________________
_______________________________________________________
_______________________________________________________
______________
Date
______________________
Patient Signature
______________________
Physician/Hyg. Signature
Medical Changes _________________________________________
_______________________________________________________
_______________________________________________________
______________
Date
______________________
Patient Signature
______________________
Physician/Hyg. Signature
Medical Changes _________________________________________
_______________________________________________________
_______________________________________________________