Date:
Updated:
Medical History
(Patient to Complete)
Name: ________________________________
Previous Surgery: _________________________________________________________
Drug Allergies: ___________________________________________________________
Habits: Alcohol: Never Rarely Daily
What Street Drugs________________
Cigarettes: Have you ever SmokedY/N
Packs Per day__ Age Started_Age Quit___
Have you ever had: (please give details)
Surgery requiring anesthesia
Complications from surgery or anesthesia
Pneumonia
Rheumatic Fever or Heart Disease
Chest Pain/Heart Attack/ Angina
Shortness of Breath
Fainting Spells
Palpitations of Heart Flutters
Anemia
Jaundice or Liver Disease
Diabetes
High Blood Pressure
Blood Transfusion
Hives
Asthma or Hay Fever
Frequent Colds or Sore Throat
Chronic or Frequent Cough
Blood Clots
Poor Circulation
Cancer
Frequent Skin Sores
Are you or could you be pregnant
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
Do you have:
Dentures
Contact Lenses
Capped Teeth
Bridges
Diseased Gums
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no
no
no
no
no
no
no
no
no
no
no
no
no
no
no
no
no
no
no
no
no
no
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
Loose Teeth
Hearing Aid
Has anyone in your immediate family (mother father sister, brother) had:
Complications from surgery or anesthesia
Chest Pain/Heart Attack/Angina
Shortness of Breath/Breathing Problems
Fainting Spells
Palpitations of Heart Flutters
Anemia
Jaundice or Liver Disease
Diabetes
High Blood Pressure
Blood Transfusion
Hives
Asthma or Hay Fever
Cancer
History of Arthritis
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
no
no
no
no
no
no
no
no
no
no
no
no
no
no
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
Medication List Please Bring Bottles In:
Name
1.________________________
2.________________________
3.________________________
4.________________________
5.________________________
6.________________________
7.________________________
8.________________________
9.________________________
Strength
_________
_________
_________
_________
_________
_________
_________
_________
_________
How many times a day
Prescribing Doctor
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
______________
______________
______________
______________
______________
______________
______________
______________
______________
Name of Family Doctor or Referring Doctor: _________________________________________
Form Completed By: ____________________________________________________________
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