Patient Medical History Form

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Medical History

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If yes, list details in the Medication Section.

Female Patients

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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.