MEDICAL HISTORY home Medical History First Name(Required) Last Name(Required) Email(Required) Patient First Name - If different Patient Last Name - If different Date of Birth(Required) MM slash DD slash YYYY Are you under a physician's care now? Yes No If yes, please explain:Have you ever been hospitalized or had a major operation? Yes No If yes, please explain the operation or procedure.Have you ever had a serious head or neck injury? Yes No If yes, please explain injury below.Please list any other serious illness you have ever had.Are you taking any medications, pills, or drugs?(Required) Yes No Are you on a special diet?(Required) Yes No Do you use tobacco?(Required) Yes No Do you use controlled substances?(Required) Yes No Are you pregnant/Trying to get pregnant? Taking Oral Contraceptives? Nursing?(Required) Yes No If yes, to any of the questions directly above, please indicate which one applies to you and which medications you are taking, if applicable.Are you allergic to any of the following?(Required) Asprin Penicillin Codeine Local Anesthetics Acrylic Metal Latex Sulfa drugs N/A Please list any other allergies.Do you take, or have taken, Phen-Fen or Redux? Phen-Fen Redux Both No Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? Yes No Have you been affected or diagnosed by any of the following?(Required) Aids/HIV Positive Alzheimer's Disease Anaphyllaxis 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 Murmur 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 Veneral Disease Yellow Jaundice N/A CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
