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HEALTH HISTORY NAME _________________________________________________________ AGE______ HT.______ WT.______ LAST FIRST MIDDLE CONFIDENTIAL OFFICE INFORMATION (Please place an X before any condition that applies to you or has applied to you in the past) _____HEART FAILURE _____HEART ATTACK _____HEART MURMUR _____RHEUMATIC FEVER _____HEART SURGERY _____ARTIFICIAL JOINT _____STROKE _____KIDNEY TROUBLE _____ULCERS _____TUBERCULOSIS _____SINUS TROUBLE _____HAYFEVER _____HEPATITIS A _____HEPATITIS B _____YELLOW JAUNDICE _____HEMOPHILIA _____COLD SORES _____CANKER SORES _____NERVOUSNESS _____CANCER _____VENEREAL DISEASE _____DIABETES _____SICKLE CELL DISEASE _____RADIATION THERAPY _____INDWELLING CATHETER _____PAIN IN JAW JOINTS _____DISEASE OF BLOOD OR BLOOD FORMING ORGANS

_____CHEST PAINS _____HIGH BLOOD PRESSURE _____SCARLET FEVER _____CONGENITAL HEART LESION _____ANEMIA _____ARTIFICIAL HEART VALVE _____EMPHYSEMA _____HEART PALPITATION _____ASTHMA _____ALLERGIES OR HIVES _____GLAUCOMA _____THYROID DISEASE _____HEPATITIS C _____LIVER DISEASE _____ARTHRITIS _____DRUG ADDICTION _____BRUISE EASILY _____BLOOD TRANSFUSION _____TUMOR _____CHEMOTHERAPY _____PACEMAKER _____FAINTING OR DIZZY SPELLS _____ORGAN TRANSPLANT _____ALCOHOLISM _____EPILEPSY OR SEIZURES _____SEVERE ALLERGIC REATION _____CHRONIC FATIGUE SYNDROME

HISTORY OF MEDICATIONS YES _____ _____ _____ _____ _____ _____ _____

NO _____ _____ _____ _____ _____ _____ _____

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YES _____ _____

NO _____ _____

HAVE YOU EVER TAKEN CORTISONE, PREDISONE, OR ANY OTHER STEROIDS? HAVE YOU EVER TAKEN ANTICOAGULANTS (BLOOD THINNERS SUCH AS COUMADIN)? HAVE YOU EVER TAKEN MEDICINES FOR HIGH BLOOD PRESSURE OR HEART DISEASE? HAVE YOU EVER TAKEN MEDICINES TO TREAT IMMUNE DEFICIENCY (AZT, PENTAMIDINE, etc.)? HAVE YOU EVER TAKEN TRANQUILIZERS OR SEDATIVES? HAVE YOU TAKEN ANY ASPIRIN WITHIN THE LAST 7-10 DAYS? ARE YOU PRESENTLY TAKING ANY MEDICINES, DRUGS, OR PILLS FOR ANY PURPOSE? IF YES, PLEASE LIST THE NAMES OF THE DRUGS, DOSAGES, AND FREQUENCY THEY ARE TAKEN.__________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ ALLERGIES-PARTICULARLY TO MEDICATIONS? PLEASE LIST_____________________________________________ __________________________________________________________________________________________________________

PHYSICAL HISTORY DO YOU HAVE ANY DIFFICULTY BREATHING THROUGH YOUR NOSE? HAVE YOU EVER HAD HIVES, WHEEZING, DIFFICULTY BREATHING, OR SWELLING WHILE TAKING ANY MEDICATION OR FOLLOWING AN INFECTION? _____ _____ HAVE YOU EVER HAD PROLONGED BLEEDING FOLLOWING ANY SURGERY? _____ _____ HAVE YOU EVER BEEN DIAGNOSED WITH ANY DISEASE INVOLVING THE IMMUNE SYSTEM? _____ _____ WOMEN: ARE YOU PREGNANT AT THIS TIME? _____ _____ DO YOU ANTICIPATE BECOMING PREGNANT IN THE IMMEDIATE FUTURE? _____ _____ ARE YOU PRACTICING BIRTH CONTROL? _____ _____ ARE YOU PRESENTLY TAKING BIRTH CONTROL PILLS? _____ _____ DO YOU SMOKE CIGARETTES, CIGARS, OR PIPES? _____ PACKS/DAY X _____ YEARS _____ _____ DO YOU WEAR CONTACT LENSES? _____ _____ HAVE YOU EVER HAD GENERAL ANESTHESIA ("been put to sleep")? _____ _____ HAVE YOU EVER BEEN DIAGNOSED WITH A CANCER OR TUMOR? IF SO WHAT AREA WAS INVOLVED? _____________________________________________________________________________________________ _____ _____ DO YOU HAVE ANY DISEASE OR CONDITION NOT LISTED? PLEASE LIST ANY PREVIOUS SURGICAL PROCEDURES AND GIVE APPROXIMATE DATES OR AGES? __________________________ _______________________________________________________________________________________________________________________________ PLEASE LIST ANY HOSPITALIZATIONS NOT RELATED TO A SURGICAL PROCEDURE? _________________________________________ _______________________________________________________________________________________________________________________________ GENERAL HEALTH EXCELLENT_____ GOOD_____ FAIR_____ POOR_____


Health history