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Patient History Form
Patient History Form
aurshax
2019-01-04T17:51:41+00:00
Patient History Form
Step 1 of 4
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Name
*
First
Last
Today's Date
*
Date Format: MM slash DD slash YYYY
Past History
Past operations
*
Yes
No
Please explain past operations
Allergies to medications
*
Yes
No
Please explain allergies to medications
Present Medications
*
Yes
No
Please List All Present Medications
Blood or Bleeding Disorders
*
Yes
No
Explain Blood or Bleeding Disorders
Severe Trauma
*
Yes
No
Explain Severe Trauma
Tuberculosis
*
Yes
No
Explain Tuberculosis
Hepatitis
*
Yes
No
Explain Hepatitis
High Blood Pressure
*
Yes
No
Explain High Blood Pressure
Diabetes
*
Yes
No
Explain Diabetes
Seizures
*
Yes
No
Explain Seizures
Post-Anesthesia Reaction
*
Yes
No
Explain Post-Anesthesia Reaction
Heart Murmur
*
Yes
No
Explain Heart Murmur
Any medical history not listed above
*
Yes
No
Explain Any medical history not listed above
Social History
Smoke
*
Yes
No
How Much Do You Smoke
Drink
*
Yes
No
How Much Do You Drink
Have you had a mold exposure?
*
Yes
No
Briefly describe the area of moisture intrusion, the time period you were exposed with approx.start date, and your symptoms
Review Of Systems (Have You Had)
Hearing loss, poor vision
*
Yes
No
Please explain hearing loss, poor vision
Recurrent sinus infections
*
Yes
No
Please explain recurrent sinus infections
Rheumatic Heart Disease
*
Yes
No
Please explain Rheumatic Heart Disease
Heart Attack
*
Yes
No
Please Explain Your Heart Attack
Pneumonia
*
Yes
No
Please Explain Your Pneumonia
Emphysema
*
Yes
No
Please Explain Your Emphysema
Bronchitis
*
Yes
No
Please Explain Your Bronchitis
Asthma
*
Yes
No
Please Explain Your Asthma
Coughing up blood
*
Yes
No
Please Explain Coughing up blood
Kidney Stones or Infection
*
Yes
No
Please Explain Kidney Stones or Infection
Bladder Infection
*
Yes
No
Please Explain Bladder Infection
Difficulty with urination
*
Yes
No
Please Explain Difficulty with urination
Stomach Ulcers
*
Yes
No
Please Explain Stomach Ulcers
History of Blood Clots
*
Yes
No
Please Explain History of Blood Clots
Blood in Stools
*
Yes
No
Please Explain Blood in Stools
Cancer
*
Yes
No
Please Explain Cancer
Thyroid Disease
*
Yes
No
Please Explain Thyroid Disease
Fainting
*
Yes
No
Please Explain Fainting
Dizzy spells
*
Yes
No
Please Explain Dizzy spells
Severe Headaches
*
Yes
No
Please Explain Severe Headaches
Any Female Disorder
*
Yes
No
Please Explain Female Disorder
Any Female Disorder
*
Yes
No
Please Explain Female Disorder
Children
*
Yes
No
Number of Children
Have you been exposed to HIV
*
Yes
No
Please Explain exposed to HIV
Are you HIV positive
*
Yes
No
Could you be pregnant
*
Yes
No
Please Notify Us BEFORE Having X-Rays
Family History (Blood Relatives)
Cancer
*
Yes
No
Who has had Cancer (Mother, Father, Grandparent, aunt, etc.)
Hearing Loss
*
Yes
No
Who has had Hearing Loss (Mother, Father, Grandparent, aunt, etc.)
High Blood Pressure
*
Yes
No
Who has had High Blood Pressure (Mother, Father, Grandparent, aunt, etc.)
Heart Attack
*
Yes
No
Who has had a Heart Attack (Mother, Father, Grandparent, aunt, etc.)
Diabetes
*
Yes
No
Who has had Diabetes (Mother, Father, Grandparent, aunt, etc.)
Bleeding Disorder
*
Yes
No
Who has had a Bleeding Disorder (Mother, Father, Grandparent, aunt, etc.)
Hepatitis
*
Yes
No
Who has had Hepatitis (Mother, Father, Grandparent, aunt, etc.)
Tuberculosis
*
Yes
No
Who has had Tuberculosis (Mother, Father, Grandparent, aunt, etc.)
By clicking submit, you're agreeing that all information given in this form is true and correct to the best of your knowledge.
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