Patient Medical History Form

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    Medical History

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    YesNo

    YesNo

    YesNo

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    YesNo

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    If yes, list details in the Medication Section.


    Female Patients

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    YesNo


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    YesNo

    ACID REFLUXADHDAIDS/HIVANEMIAANOREXIAANXIETYARTIFICIAL HEART VALVEARTIFICIAL JOINTSARTHRITISASTHMAAUTISM/ASPERGER'SBLEEDING DISORDERBULIMIACANCER/MALIGNANCYCEREBRAL PALSYCHEMICAL DEPENDENCYCHICKEN POXCONVULSIONSDEPRESSIONDIABETESDIZZINESS/FAINTINGEPILEPSY/SEIZURESFREQUENT EAR INFECTIONSFREQUENT HEADACHESHEARING PROBLEMSHEART ATTACKHEART DISEASEHEART MURMURHEPATITISHIGH BLOOD PRESSUREKIDNEY DISEASELIVER PROBLEMSMITRAL VALVE PROLAPSEMONONUCLEOSISPACEMAKERPSYCHIATRIC TREATMENTRADIATION/CHEMORESPIRATORY DISEASERHEUMATIC FEVERSINUS PROBLEMSSTROKETHYROID CONDITIONTUBERCULOSISULCERSVENEREAL DISEASEOTHER (Explain below)None of these

    ASPIRINANESTHETIC – LOCALBARBITURATESCODEINEDAIRYLATEXLACTOSE INTOLERANCEMETAL SENSITIVITYNITROUS OXIDE SEDATIONSLEEPING PILLSSULFA DRUGSPENICILLIN/OTHER ANTIBIOTICSOTHER (Explain below)None of these


    Medication Information

    ANTIBIOTICS/SULFA DRUGSBLOOD THINNERSINSULINOTHER DIABETIC MEDICATIONSOTHER (VITAMINS)ANTIHISTAMINES/ALLERGYCANCER/CHEMO MEDICATIONSNITROGLYCERINRECREATIONAL DRUGSDAILY ASPIRINCORTISONE/STEROIDSORAL CONTRACEPTIVESTHYROID MEDICATIONSBLOOD PRESSURE MEDICATIONSHEART MEDICATION/DIGITALISOSTEOPOROSIS MEDICATIONSTRANQUILIZERS

    Please list any additional medications.