Patient Medical Information Form Step 1 of 9 11% Patient's Name:*FirstLastDate of Birth:* Gender*MaleFemaleHave you been a patient in the hospital during the past year?*YesNoIn the past two (2) years, have you had a serious illness requiring a physicians care?*YesNoPhysician's Name:*Dentist's Name:*List Medications/drugs you are taking:List prior operations: Indicate which of the following you have had or have at present. Check the box next to each item to indicate YES: StrokeHeart SurgeryHeart Disease or AttackRheumatic FeverAngina PectorisArtificial Heart ValveHeart MurmurArtificial JointsHigh/Low Blood PressureTMJ ProblemsMitral Valve ProlapseLymes DiseaseHeart PacemakerSevere/Frequent headaches Indicate which of the following you have had or have at present. Check the box next to each item to indicate YES: Psychiatric ProblemsRadiation TherapyUlcersOsteoporosis TherapyDiabetesEmphysemaThyroid ProblemsTuberculosisGlaucomoaAsthmaCancerAllergies or HivesChemotherapySinus Problems Indicate which of the following you have had or have at present. Check the box next to each item to indicate YES: HepatitisHemopheliaLiver DiseaseAnemiaA.I.D.S.Sickle Cell DiseaseH.I.V. PositiveBruise EasilyVenereal DiseaseEpilepsy or SeizuresCold Sores/Fever BlistersFainting or Dizzy SpellsBlood TransfusionDrug Addiction Have you ever taken prescription medication for weight reduction (diet pills)?*YesNoIf yes:Fen-Phen (fenfluramine + phentermine)Pondimin (fenfluramine)Redux (dexfenfluramine)Do you take health food supplements (ginko, St. Johns wort, vitamin E, ginseng)?*YesNo Are you sensitive or allergic to any of the following? Check the box next to each item to indicate YES: PenicillinErythromycinTetracyclineSulfaCodeineAspirin/IbuprofenTylenol/AcetaminophenSteroidsLatexLocal AnestheticsFood (e.g. egg, soy)Other: Do you smoke?*YesNoIf yes, how much per day?Do you drink alcohol?*YesNoIf yes, how much per day?Do you have any disease, condition or problem not listed?*YesNoIf yes, please list: Are you taking birth control pills?*YesNoAre you nursing?*YesNoAre you pregnant?*YesNoIf yes, what month?Please enter a value between 0 and 10. By typing my full name below, I am acknowledging that I understand the entered information is necessary to provide safe surgical treatment. I have answered all questions truthfully and to the best of my knowledge. If patient is a minor, parent please digitally sign below. Full Name:*or Parent if minorToday's Date:*NameThis field is for validation purposes and should be left unchanged.