Medical History Questionnaire
NAME: _________________________________________
TODAY’S DATE: __________________ First Middle Initial Last
DATE OF BIRTH: __________________
This questionnaire was designed to provide important facts regarding the history of your pain or condition. The information you provide will assist in reaching diagnosis and determining the source of your problem. Plea take your time and answer each question as completely and honestly as possible. Plea sign every page.
N Antibiotics Y N Latex
Y N Sedatives N Aspirin
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Y N Local anesthetics Y N Sleeping pills N Barbiturates Y N Metals Y N Sulfa drugs
N Codeine Y N Penicillin Y N N
Iodine
Y N
Plastic
Y N
Other ______________________ ________________________ _________________________
LIST ANY MEDICATIONS CURRENTLY BEING TAKEN:
Medication
Dosage/Frequency
路由器动态ipReason
交通安全标识_________________________ _____________________ _______________________________________________ _________________________ _____________________ _______________________________________________ _________________________ _____________________ _______________________________________________ _________________________ _____________________
_______________________________________________ MEDICAL HISTORY: (Plea indicate dates on items marked current or past)
Medical Condition
Medical Condition
Acid reflux
Insomnia
Adenoids Removed
Intestinal disorder Anemia
Jaw joint surgery Arteriosclerosis
Kidney problems Arthritis
liver dia Asthma
Low energy
Autoimmune disorder Meniere's dia Bleeding easily
Menstrual cramps Blood pressure - High
Multiple sclerosis Blood pressure - Low Muscle aches
Botox
Muscle shaking (tremors) Bruising easily
Muscle spasms or cramps Cancer
Muscular dystrophy Chemotherapy
Nasal allergies
Chronic cough
Needing extra pillow to help Chronic fatigue
breathing at night
Chronic pain
Nervous system irritability Cold hands and feet Nervousness COPD
Neuralgia
Depression
Numbness of fingers Diabetes
Osteoarthritis Difficulty concentrating
Osteoporosis
Patient Signature ______________________________ Date _________________________ Page 1
Medical condition Never Current Past Medical condition Never Current Past
眼皮总是跳是什么原因
Difficulty sleeping Ovarian cysts Dizziness Parkinson's dia Emphyma Poor circulation
Epilepsy Prior orthodontic treatment Excessive thirst Psychiatric care Fibromyalgia Radiation treatment Fluid retention Rheumatic fever Frequent cough Rheumatoid arthritis Frequent illness
Scarlet fever Frequent stressful situations Scoliosis
General anesthesia Shortness of breath Glaucoma Sinus problems Gout Skin disorder Hay Fever Sleep apnea Hearing impaired Slow healing sores Heart attack
Speech difficulties Heart disorder Stroke
Heart murmur Swelling in ankles or feet Heart pacemaker Swollen, stiff or painful joints Heart valve replacement Tendency for ear infections Hemophilia Tendency for frequent colds Hepatitis Tendency for sore throats Hypertension Thyroid disorder Hypoglycemia
Tired muscles Immune system disorder Tonsils removed Injury to face Tuberculosis Injury to mouth Tumors Injury to neck
Urinary disorders Injury to teeth
Wisdom teeth extraction
Medical condition
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Medical condition Other ____________________
ADDITIONAL MEDICAL HISTORY ITEMS:
Recreational Drugs HIV/AIDS
N Appendectomy Y N Heart
Y
N Thyroid
N Back Y N Hernia repair Y N Tonsillectomy
N Ear
Y N Lung Y N Uvulectomy N
Gallbladder
Y N
Nasal
Y N
Periodontal
Patient Signature _________________________________
Date____________________
Page 2
FAMILY HISTORY Has any member of your family had (parent, sibling or grandparent):
Y
N
Cancer Y
N
Sleep disorder Y起小名男孩
N
Father snores
Y N Heart dia Y N Obesity Y N
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Mother snores
Y
N
Diabetes
Y N
Thyroid trouble
Y
N
Father has sleep apnea Y N Stroke Y N High blood pressure Y N Mother has sleep apnea SOCIAL HISTORY:
Tobacco U:smoked
Alcohol U:
Caffeine Intake:None Coffee/Tea/Soda #cups per day: _______
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Additional:
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