Health history

Please submit the electronic form below, or you may print this FORM and bring it into the office.


    YesNo

















    NursingTaking oral contraceptive


    AspirinPenicillinCodeineAcrylic
    MetalLatexSulfa DrugsLocal Anesthetics


    YesNo


    YesNo


    AIDS/HIV PositiveExcessive ThirstMitral Valve Prolapse
    Alzheimer's DiseaseFainting Spells/DizzinessOsteoporosis
    AnaphylaxisFrequent CoughPain in Jaw Joints
    AnemiaFrequent HeadachesParathyroid Disease
    AnginaGenital HerpesPsychiatric Care
    Arthritis/GoutGlaucomaRadiation Treatments
    Artificial Hearth ValveHay FeverRecent Weight Loss
    Artificial JointHearing ImpairmentRenal Dialysis
    AsthmaHeart Attack/FailureRheumatic Fever
    Blood DiseaseHeart MurmurRheumatism
    Blood TransfusionHeart PacemakerScarlet Fever
    Breathing ProblemsHeart Trouble/DiseaseShingles
    Bruise EasilyHemophiliaSickle Cell Disease
    CancerHepatitis ASinus Trouble
    ChemotherapyHepatitis B or CSpina Bifida
    Chest PainsHerpesStomach/Intestinal Disease
    Cold Sores/Fever BlistersHigh Blood PressureStroke
    Congenital Heart DisorderHigh CholesterolSwelling of Limbs
    ConvulsionsHives or RashThyroid Disease
    Cortisone MedicineHypoglycemiaTonsillitis
    DiabetesIrregular HeartbeatTuberculosis
    Drug AddictionKidney ProblemsTumors or Growths
    Easily WindedLeukemiaUlcers
    EmphysemaLiver DiseaseVenereal Disease
    Epilepsy or SeizuresLow Blood PressureYellow Jaundice
    Excessive BleedingLung Disease