Medical History









    Women: Are you...
    Pregnant/Trying to get pregnant?Nursing?Taking oral contraceptives?

    Are you allergic to any of the following?
    AspirinMetalPenicillinLatexCodeineSulfa DrugsAcrylicLocal Anesthetics

    Other?
    If yes

    Do you have, or have you had, any of the following?
    AIDS/HIV PositiveYesNo
    Alzheimer's DiseaseYesNo
    AnaphylaxisYesNo
    AnemiaYesNo
    AnginaYesNo
    Arthrities/GoutYesNo
    Artificial Heart ValveYesNo
    Artificial JointYesNo
    AsthmaYesNo
    Blood DiseaseYesNo
    Blood TransfusionYesNo
    Breathing ProblemsYesNo
    Bruise EasilyYesNo
    CancerYesNo
    ChemotherapyYesNo
    Chest PainsYesNo
    Cold Sores/Fever BlistersYesNo
    Congenital Heart DisorderYesNo
    ConvulsionsYesNo
    Cortisone MedicineYesNo
    DiabetesYesNo
    Drug AddictionYesNo
    Easily WindedYesNo
    EmphysemaYesNo
    Epilepsy or SeizuresYesNo
    Excessive BleedingYesNo
    Excessive ThirstYesNo
    Fainting Spells/DizzinessYesNo
    Frequent CoughYesNo
    Frequent DiarrheaYesNo
    Frequent HeadachesYesNo
    Genital HerpesYesNo
    GlaucomaYesNo
    Hay FeverYesNo
    Heart Attack/FailureYesNo
    Heart MurmurYesNo
    Heart PacemakerYesNo
    Heart Trouble/DiseaseYesNo
    HemophiliaYesNo
    Hepatitis AYesNo
    Hepatitis B or CYesNo
    HerpesYesNo
    High Blood PressureYesNo
    High CholesterolYesNo
    Hives or RashYesNo
    HypoglycemiaYesNo
    Irregular HeartbeatYesNo
    Kidney ProblemsYesNo
    LeukemiaYesNo
    Liver DiseaseYesNo
    Low Blood PressureYesNo
    Lung DiseaseYesNo
    Mitral Valve ProlapseYesNo
    OsteoporosisYesNo
    Pain in Jaw JointsYesNo
    Parathyroid DiseaseYesNo
    Psychiatric CareYesNo
    Radiation TreatmentsYesNo
    Recent Weight LossYesNo
    Renal DialysisYesNo
    Rheumatic FeverYesNo
    RheumatismYesNo
    Scarlet FeverYesNo
    ShinglesYesNo
    Sickle Cell DiseaseYesNo
    Sinus TroubleYesNo
    Spina BifidaYesNo
    Stomach/Intestinal DiseaseYesNo
    StrokeYesNo
    Swelling of LimbsYesNo
    Thyroid DiseaseYesNo
    TonsillitisYesNo
    TuberculosisYesNo
    Tumors or GrowthsYesNo
    UlcersYesNo
    Venereal DiseaseYesNo
    Yellow JaundiceYesNo
    Have you ever had any serious illness not listed above?YesNo
    If yes
    Comments
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