Medical information

Your Name:
1. Have you been under a doctor's care during the past year?   If yes, please explain  
2. Have you ever been hospitalized?   If yes, please explain  
3. Have you ever had any operations?   If yes, please explain  
4. Have you ever had any of the following?  (Please check Y or N for each one)
Heart Disease
Open heart surgery
Heart murmur
Mitral Valve Prolapse
High Blood Pressure
Tobacco (smoke/chew)
Respiratory problems, i.e. emphysema, bronchitis
Stomach ulcers
Liver Disease (cirrhosis, hepatitis)
Bleeding disorder
Bone Disorder
Artificial Joints
Radiation Therapy
5. Have you had any disease, drug or transplant operation that has depressed your immune system?   If yes, please explain  
6. Are you taking Bisphosphonates (Fosamax, Boniva, Actonel, Aredia, Zometa, Reclast, Prolia) for osteoporosis, chemotherapy or multiple myeloma, etc.?  
7. Do you have any past history of chemical or alcoholic dependency that may affect the care we provide?  
8. Are you taking any of the following?
Anticoagulants(blood thinners)
Aspirin/drugs (Motrin, Aleve, Ibuprofen)
High blood pressure drugs
Insulin or Oral Anti-Diabetic drugs
Steroids (Cortisone, etc.)
Digitalis, Inderal Nitroglycerin or other heart drugs
9. Please list any and all medications you are currently taking, including prescription medications, over-the-counter medications, herbal or holistic remedies, vitamins or minerals
10. Are you allergic or have you had an adverse reaction to:
Local anesthesia (Novocain, etc.)
Penicillin/ Amoxicillin
Other antibiotics?
Other allergies or reactions?
Aspirin or Ibuprofen
Latex or Rubber Products
Please List:  
Please List:  
Codeine or other pain killers
Sedatives, barbiturates
11. For Women Only: Are you pregnant/any chance you might be pregnant?  
Are you nursing?  
**If you are using Oral Contraceptives, it is important that you understand that antibiotics (and some other medications) may interfere with the effectiveness of oral contraceptives. Please consult with your physician.
12. Do you wish to speak with the doctor privately about anything?