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NAME ____________________________ HEIGHT_______ WEIGHT _______
MEDICAL HISTORY
Have you/do you smoke cigarettes? No Yes amount/how long/I quit ______________
Present medications including aspirin & herbal medications: _______________________________________________________________________
List all allergies to medications: _______________________________________________
List all other known allergies: _________________________________________________
List all surgery within the past 5 years: __________________________________________
Previous hospitalizations: ___________________________________________________
Female patients only: Are you taking oral contraceptives? Yes No Are you pregnant or trying to become pregnant? Yes No
Please indicate any medical problems: Heart Disease High Blood Pressure Heart Attack Chest Pain Lung Disease Stroke Blood Clots Leg Swelling Liver Disease Hepatitis Anemia Kidney Disease Diabetes Infectious Disease Neurologic Psychiatric Care Shortness of Breath Cancer or Skin Cancer Bone or Joint Other: ____________________________________________________________________________________
Family History of Skin Disease: Yes No If yes, what type: _____________________
Do you have an artificial heart valve, joint or other prosthesis that requires you to take antibiotics when you have dental procedures? Yes No If yes, what antibiotic: __________________________________________
Are you allergic to band aids, tape, or adhesive? Yes No
Have any members of your family had skin cancer? Yes No
Do any diseases run in your family? Yes No
Please list any other information that we need to know about: ________________________________________________________________________
I hereby authorize the physician, therapist or his/her representative to leave messages on my answering machine Yes No
Signature: _________________________________ Date: ______________
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