Medical History
Full Name
*
First Name
MI
Last Name
Are you currently under a physician's care for any ongoing treatment?
Yes
No
If yes, please list Physician's name and explain:
Have you recently been hospitalized or have had any major operations?
Yes
No
If yes, please list dates and explain:
Have you ever had a serious head or neck injury?
Yes
No
If yes, please list dates and explain:
Please list any medications you are currently taking along with dosage and frequency:
Check if you are allergic to any of the following:
Aspirin
Acrylic
Penicillin
Metal
Codeine
Latex
Local Anesthetics
Sulfa Drugs
Other
If "Other" please explain:
Please check if you have, or have had in the past, any of the following:
AIDS/HIV Positive
Drug Addiction
Herpes
Rheumatism
Alzheimer's Disease
Easily Winded
High Blood Pressure
Scarlet Fever
Anaphyaxis
Emphysema
High Cholesterol
Shingles
Anemia
Epilepsy or Seizures
Hives or Rash
Sickle Cell Disease
Arthritis/Gout
Excessive Bleeding
Hypoglycemia
Sinus Trouble
Artificial Joint
Fainting/Dizzy Spells
Irregular Heartbeat
Spina Bifida
Asthma
Frequent Cough
Kidney Problems
Stomach/Intestinal Disease
Blood Disease
Frequent Diarrhea
Leukemia
Stroke
Blood Transfusion
Frequent Headaches
Liver Disease
Swelling of Limbs
Breathing Problems
Genital Herpes
Low Blood Pressure
Thyroid Disease
Bruise Easily
Glaucoma
Lung Disease
Tonsilitis
Cancer
Hay Fever
Mitral Valve Prolapse
Tuberculosis
Chemotherapy
Heart Attack/Failure
Osteoporosis
Tumors or Growths
Chest Pains
Heart Murmur
Pain in Jaw Joints
Ulcers
Cold Sores/Fever Blisters
Heart Pacemaker
Parathyroid Disease
Venereal Disease
Congenital Hear Disorder
Heart Trouble/Disease
Psychiatric Care
Yellow Jaundice
Hepatitis A
Hemophilia
Radiation Treatments
Convulsions
Rheumatic Fever
Renal Dialysis
Recent Weight Loss
Hepatitis B or C
Angina
Diabetes
Cortisone Medicine
Other
If "Other" please explain:
Submit
Should be Empty: