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Patient Medical History
Patient Medical History
Patient Information
First Name
*
Last Name
*
Middle Initial
Birth Date
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
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Year
Year
1921
1922
1923
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2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
I would like to receive correspondences via email.
yes
no
Referred By
Are you under a physician's care now?
yes
no
If yes
Have you ever been hospitalized or had a major operation?
yes
no
If yes
Have you ever had a serious head or neck injury?
yes
no
If yes
Are you taking any medications, pills, or drugs?
yes
no
If yes
Do you take, or have you taken, Phen-Phen or Redux?
yes
no
If yes
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
yes
no
If yes
Are you on a special diet?
yes
no
Do you use tobacco?
yes
no
Do you use controlled substances?
yes
no
If yes
Women: Are you
Pregnant/Trying to get pregnant?
yes
no
Taking Oral Contraceptives?
yes
no
Nursing?
yes
no
Are you allergic to any of the following?
aspirin
penicillin
codeine
local anesthetics
acrylic
metal
latex
sulfa drugs
Other
yes
If yes
Do you have or have you had, any of the following?
AIDS/Hiv Positive
Alzheimer's Disease
Anaphylaxis
Anemia
Angina
Arthritis/Gout
Artificial Heart Valve
Artificial Joint
Asthma
Blood Disease
Blood Transfusion
Breathing Problem
Bruise Easily
Cancer
Chemotherapy
Chest Pains
Cold Sores/Fever Blisters
Congenital Heart Disorder
Convulsions
Cortisone Medicine
Diabetes
Drug Addiction
Easily Winded
Emphysema
Epilepsy or Seizures
Excessive Bleeding
Excessive Thirst
Fainting Spells/Dizziness
Frequent Cough
Frequent Diarrhea
Frequent Headaches
Genital Herpes
Glaucoma
Hay Fever
Heart Attack/Failure
Heart Pacemaker
Heart Trouble/Disease
Hemophilia
Hepatitis A
Hepatitis B or C
Herpes
High Blood Pressure
High Cholesterol
Hives or Rash
Hypoglycemia
Irregular Heartbeat
Kidney Problems
Leukemia
Liver Disease
Low Blood Pressure
Lung Disease
Mitral Valve Prolapse
Osteoporosis
Pain in Jaw Joints
Parathyroid Disease
Psychiatric Care
Radiation Treatments
Recent Weight Loss
Renal Dialysis
Rheumatic Fever
Rheumatism
Scarlet Fever
Shingles
Sickle cell Disease
Sinus Trouble
Spina Bifida
Stomach/Intestinal Disease
Stroke
Swelling of Limbs
Thyroid Disease
Tonsillitis
Tuberculosis
Tumors or Growths
Ulcers
Venereal Disease
Yellow Jaundice
Have you ever had any other serious illness not listed above?
Do you have or have you had, any of the following? Have you ever had any other serious illness not listed above?
If yes
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