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
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