MedicalHistory

Do you require Antibiotic pre-medication?

Is there any disease, condition, or problem that you think this office should know about that has not been covered in the medical history? If yes, please describe below.

Please list any medication you are currently taking:

Do you smoke or use tobacco?

Are you taking Birth Control Pills?

Are you pregnant?

Are you nursing? If yes, # of weeks:

FOR OFFICE USE ONLY:

BP Heart Rate

Signature:
(If Submitting on-line, please sign paper on next visit to our office.)

NAME:					DATE:

Y	N	CONDITIONS	Y	N	CONDITIONS	Y	N
		Abnormal Bleeding/Hemophilia			Heart Surgery			Are you allergic to any of the following?
		Alcohol/Drug Abuse			Hepatitis A or B			Aspirin
		Allergies			High/Low Blood Pressure			Codeine
		Anemia			Kidney Problems			Dental Anesthetics
		Angina Pectoris			Liver Disease			Erythromycin
		Arthritis			Mitral Valve Prolapse			Jewelry
		Artificial Bones/Joints			Osteoporosis Drugs			Latex
		Artificial Heart Valve			Pace Maker			Latex
		Asthma			Pain in Jaw Joints			Metals
		Cancer - Chemotherapy			Psychiatric Problems			Penicillin
		Congenital Heart Defect			Radiation Therapy			Tetracycline
		Diabetes			Rheumatic Fever			Sulfa
		Difficulty Breathing			Shingles			Other
		Emphysema			Sickle Cell Disease
		Fainting/Seizures/Epilepsy			Sinus Problems
		Fever Blisters			Stroke
		Frequent Headaches			Thyroid Problems
		Glaucoma			Tuberculosis
		HIV+ AIDS			Ulcers
		Heart Attack			Venereal Disease
		Heart Disease
		Heart Murmur

		Do you require Antibiotic pre-medication?
		Is there any disease, condition, or problem that you think this office should know about that has not been covered in the medical history? If yes, please describe below.

		Please list any medication you are currently taking:


		Do you smoke or use tobacco?
		Are you taking Birth Control Pills?
		Are you pregnant?
		Are you nursing? If yes, # of weeks:			FOR OFFICE USE ONLY: BP Heart Rate
					FOR OFFICE USE ONLY: BP Heart Rate
Signature: (If Submitting on-line, please sign paper on next visit to our office.)
	or and Mail or bring in to our office at 550 Chesnut St . , Conway AR 72032 (Corner of Chesnut & Deer St.)