MEDICAL HISTORY
Excellent Good Fair Poor
DO YOU HAVE or HAVE YOU EVER HAD
YES
NO
1. Hospitalization for illness or injury
2. An allergic reaction to
aspirin, ibuprofen, acetaminophen, codeine
penicillin
erythromycin
tetracycline
sulfa
local anesthetic
fluoride
metals (nickel, gold, silver,
)
latex
other
3. Heart problems/cardiac stent last 6 months
4. History of infective endocarditis
5. Artificial heart valve, repaired heart defect
6. Pacemaker or implantable defibrillator
7. artificial prosthesis (heart valve or joints)
8. Rheumatic or scarlet fever
9. High or low blood pressure
10. A stroke (taking blood thinners)
11. Anemia or other blood disorder
12. Prolonged bleeding due to a slight cut
13. Emphysema, sarcoidosisy
14. Tuberculosis
15. Asthma
16. Breathing or sleep problems (i.e. sleep apnea, snoring, sinus)
17. Kidney disease
18. Liver disease
19. Jaundice
20. Thyroid or parathyroid disease
21. Hormone deficiency
22. High cholesterol or taking statin drugs
23. Diabetes (HbA1c =
)
24. Stomach or duodenal ulcer
25. Digestive disorders (i.e. gastric reflux)
DO YOU HAVE or HAVE YOU EVER HAD
YES
NO
26. Osteoporosis/osteopenia (i.e. taking bisphosphonates)
27. Arthritis, rheumatoid arthritis, lupus
28. Glaucoma
29. Contact lenses
30. Head or neck injuries
31. Epilepsy, convulsions (seizures)
32. Neurologic disorders (e.g. ADD/ADHD)
33. Viral infections and cold sores
34. Any lumps or swelling in the mouth
35. Hives, skin rash, hay fever
36. Venereal disease (STI/STD)
37. hepatitis (type
)
38. HIV / AIDS
39. Tumor, abnormal growth
40. Radiation therapy
41. Chemotherapy, immunosuppressive drugs
42. Psychological or behavioral issues
43. Psychiatric treatment
44. Antidepressant medication
ARE YOU:
45. Presently being treated for other illness
46. Aware of a change in your health (i.e. fever, chills, new cough, diarrhea)
47. Taking medication for weight management (i.e. fen-phen)
48. Taking dietary supplements
49. Often exhausted or fatigued
50. Experiencing frequent headaches
51. A smoker, smoked previously or use smokeless tobacco
52. Often unhappy or depressed
53. FEMALE - taking birth control pills
54. FEMALE - pregnant
55. MALE - prostate disorders
Drug
Purpose
Drug
Purpose