Medical History Form - Maple Grove

Medical History Form

Are you under a physician's care now?

Yes No
If yes:

Have you ever been hospitalized or had a major operation?

Yes No
If yes, please list:

Have you ever had a serious head or neck injury?

Yes No
If yes:

Are you taking any medications, pills, or drugs?

Yes No
If yes, please list:

Do you take, or have you taken, Phen-Fen or Redux?

Yes No

Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?

Yes No

Are you on a special diet?

Yes No

Do you use tobacco?

Yes No

Women: Are you...

Pregnant/Trying to get pregnant? Nursing? Taking oral contraceptives?

Are you allergic to any of the following?

AspirinAcrylicCodeineLatex

Local AnestheticsMetalPenicillinSulfa Drugs

Other Allergies?

Do you use controlled substances?

Yes No
If yes, please list:

Do you have, or have you had, any of the following?

AIDS/HIV PositiveAlzheimer's DiseaseAnaphylaxisAnemiaAnginaArthritis/GoutArtificial Heart ValveArtificial JointAsthmaBlood DiseaseBlood TransfusionBreathing ProblemsBruise EasilyCancerChemotherapyChest PainsCold Sores/Fever BlistersCongenital Heart DisorderConvulsionsCortisone MedicationDiabetesDrug AddictionEasily WindedEmphysemaEpilepsy or SeizuresExcessive BleedingExcessive ThirstFainting Spells/DizzinessFrequent CoughFrequent DiarrheaFrequent HeadachesGenital HerpesGlaucomaHay FeverHeart Attack/FailureHeart MurmurHeart PacemakerHeart Trouble/Disease

HemophiliaHepatitis AHepatitis B or CHerpesHigh Blood PressureHigh CholesterolHives or RashHypoglycemiaIrregular HeartbeatKidney ProblemsLeukemiaLiver DiseaseLow Blood PressureLung DiseaseMitral Valve ProlapseOsteoporosisPain in Jaw JointsParathyroid DiseasePsychiatric CareRadiation TreatmentsRecent Weight LossRenal DialysisRheumatic FeverRheumatismScarlet FeverShinglesSickle Cell DiseaseSinus TroubleSpina BifidaStomach/Intestinal DiseaseStrokeSwelling of LimbsThyroid DiseaseTonsillitisTuberculosisTumors or GrowthsUlcersVenereal Disease

Yellow Jaundice

Have you ever had any serious illness not listed?

Yes No
If yes, please list:

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