Please enable JavaScript in your browser to complete this form.1Existing Patient Medical History Update2Updated Medical History QuestionnairePATIENT DETAILSPatient Legal Name *FirstMiddleLastDate of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920NextPlease Provide Honest And Accurate Information So We Can Best Care For YouIf you have any questions about the information we are requesting please let us knowMEDICAL HISTORY QUESTIONAIREDo you have any of the listed medical conditions?Current Medical ConditionsActive Tuberculosis Persistent cough greater than 3 weeks in durationCough that produces bloodBeen exposed to anyone with TuberculosisWhat Is Your Impression Of Your Health? *ExcellentGoodFairPoorAre you now, or have you been in the past year, under the care of a physician? *NoYesHave you had any serious illness, operation, or been hospitalized in the past 5 years? *NoYesHave you had an organ transplant? *NoYesDo you have a history of Endocarditis (infected heart valve)? *NoYesHave you had open heart surgery? *NoYesHave you ever had any radiation therapy or chemotherapy for a growth, tumor or other condition? *NoYesIn the last 2 years, have you taken or are you now taking steroids (e.g. cortisone)? *NoYesDo you use or have you used tobacco (smoking, snuff, chew, vape? *NoYesHave you taken, are you taking or are you scheduled to begin taking oral bisphosphonates? *NoYesOral bisphosphonates: Alendronate (Fosamex, Fosamex Plus D), Etidronate (Didronel), Ibandronate (Boniva), Risedronate (Actonel), Tiludronate (Skelid)?Have you taken, are you taking or are you scheduled to begin taking IV bisphosphonates? *NoYesIntravenous bisphosphonates: Clodronate (Bonefos), Pamidronate (Aredia) or Zolodronic Acid (Reclast, Zometal)?WOMEN ONLYWomen's Medical ConditionsAre you pregnant?Are you trying to become pregnant?Are you nursing?Are you taking birth control pills, fertility drugs or hormonal replacement?Please check all that applyALLERGIESAre you allergic to or have you had a reaction to any of the following?Other MedicationsLocal anesthetics (or their preservatives)Hay fever/seasonal (allergic rhinitis)PenicillinAnimalsSulfa drugsMetals/Jewelry (nickel/chrome)Other antibioticsFoodCodeine or other narcoticsIodineAspirinLatex (rubber)Barbiturates (sedatives or sleeping pills)Please check all that applySPECIFIC MEDICAL CONDITIONSCardiovascular/Heart problems?Rheumatic fever/ heart diseaseHigh blood pressureInfective endocarditisLow blood pressureArtificial heart valvesArteriosclerosisCongenital heart defectPalpitationsHeart murmurArrhythmia (irregular heart beat)Mitral valve prolapseShortness of breathAngina (chest pain)Swelling of the anklesHeart attackPacemakerHeart failureImplantable defibrillatorCoronary heart diseaseSleep on two or more pillowsPlease check all that applyRespiratory/Lung problems?AsthmaSinusitisEmphysema/COPDBronchitisTuberculosisPersistent coughSarcoidosisSleep apneaPneumoniaSnoringPlease check all that applyDiabetes/Endocrine disorders?DiabetesThyroid problemsAdrenal gland disorderPlease check all that applyKidney/Urogenital disorders?Kidney stonesProstateRenal failure/insufficiencyFrequent urinationDialysisPlease check all that applyCancer or Tumors?YesNoNeurologic/Nerve Problems?StrokeWeaknessTIA (transient ischemic attack)Feeling of tingling or numbnessSeizures/epilepsyMental health disorderMultiple sclerosisPost-traumatic stress disorderParkinson’s diseaseObsessive/compulsive disorderNeuropathiesADD/ADHD (attention deficit disorder)Dementia/Alzheimer’s (memory loss)Feelings of anxietyHeadacheFeelings of depressionFainting or dizzy spellsPlease check all that applyBlood/Hematologic disorders?AnemiaLeukemiaThalassemiaLymphomaSickle cell disease/traitMultiple myelomaDeep vein thrombosisBleeding disordersBruise easilyPlease check all that applyGastrointestinal (GI) disorders?Cirrhosis/chronic hepatitisGall stonesJaundice (skin/eyes turn yellow)UlcersHepatitisCrohn’s diseaseHeart burnIrritable bowel syndromeAcid reflux (GERD)Please check all that applyMusculoskeletal/Connective tissue disorders?ArthritisLupusOsteoporosisSclerodemaGoutFibromyalgiaTemporomandibular joint disorderJoint replacementPlease check all that applyInfectious diseases?HIVSTDAIDSCold soresMethicillin-resistant Staph aureus (MRSA)MononucleosisPlease check all that applyHead/Eye/Ear/Nose/Throat problems?Vision problemsCataractWear contact lensesHearing impairmentGlaucomaPlease check all that applyImmunosuppression *YesNoAre you taking any Anticoagulant or Blood Thinner medications? *YesNoIf yes, please describe drug, dose, and durationMEDICATION AND SUPPLEMENT USEIf you are taking, have recently (within the last month) taken, or are supposed to be taking any medications (prescription, over the counter) please specify medication(s), dosage and frequency ADDITIONAL INFORMATIONIf there is any additional information you would like to add or clarify please add it below.Submit
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