Medical Health History

Do you have, or have you had any of the following?

YesNo
Local anesthetics (Novocaine)
Penicillin or other antibiotics
Sulfa drugs
Barbiturates, sedatives,or sleeping pills
Aspirin, Acetaminophen, or Ibuprofen
Codeine, Demerol, or other narcotics
Reaction to metals
Latex or rubber dam
YesNo
Antibiotics or sulfa drugs
Anticoagulants (e.g. Coumadin)
High blood pressure medicine
Tranquilizers
Insulin, Orinase, or similar drug
Aspirin
Digitalis or drugs for heart trouble
Nitroglycerin
Cortisone (steroids)
Natural remedies
Nonprescription drug/supplements
YesNo
Are you taking contraceptives or other hormones?
Are you pregnant? If so, expected delivery date:
Are you nursing?
Have you reached menopause? If so, do you have any symptoms?
YesNo
Chest pain
Shortness of breath
Blood pressure problem
Heart murmur
Heart valve problem
Taking heart medical
Rheumatic fever
Pacemaker
Artificial heart valve
YesNo
Easy bruising
Frequent nosebleeds
Abnormal bleeding
Blood disease (anemia)
Ever require a blood transfusion?
YesNo
Hay fever
Sinus problems
Skin rashes
Taking allergy medication
Asthma
YesNo
Ulcers
Weight gain or loss
Special diet
Constipations/ Diarrhea
Kidney or bladder problems
YesNo
Arthritis
Back or neck pain
Joint replacement ( e.g., total hip, pins, or implants)
YesNo
Urinate more than 6 times a day
Thirsty or mouth is dry much of the time
Family history of diabetes
YesNo
Fainting Spells, Seizures, or Epilepsy
Stroke(s)
Frequent or severe headaches
Thyroid problems
Persistent cough or swollen glands
Premedications required by physician
Cancer/ Tumor
Do you drink alcohol?
Tuberculosis or other respiratory disease
Hepatitis, jaundice, or liver trouble
Herpes or other STD
HIV-positive/AIDS
Glaucoma
Do you wear contact lenses?
History of head injury?
Epilepsy or other neurological disease?
History of alcohol or drug abuse?