Medical History Form
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MEDICAL HISTORY FORM 1. Name: ______ ____________ Date__________________________________ 2. Did another doctor refer you to Dr. Biesman? If yes, please provide his/her name, address, and telephone number: _____________________________________________________________________________________________ 3. What is the name and address of your family doctor? ________________________________________________ 4. Who is your regular eye doctor? MD or OD? _______________________________________________________ 5.
Are you allergic to any medications? YES NO If yes, what are they? _________________________________ _____________________________________________________________ If yes, describe your reaction (s) _________________________________________________________________
6. Medical History: Have you ever had: a.
Diabetes mellitus
Date of Onset YES
NO
________________________________________
Diet control ___ Oral agents ___ Insulin ___ b.
Heart attack
YES
NO
________________________________________
Angina or chest pain
YES
NO
________________________________________
Heart failure
YES
NO
________________________________________
Irregular heart beat
YES
NO
________________________________________
c.
High blood pressure
YES
NO
________________________________________
d.
Stroke or "mini stroke"
YES
NO
________________________________________
e.
Anemia
YES
NO
________________________________________
f
Asthma, emphysema, tuberculosis YES
NO
________________________________________
g.
Liver disease, hepatitis, jaundice
YES
NO
________________________________________
h.
Stomach ulcers
YES
NO
________________________________________
i.
Kidney disease or stones
YES
NO
________________________________________
j.
Arthritis (if yes, specify type)
YES
NO
________________________________________
k.
Skin cancer
YES
NO
________________________________________
l.
Other types of cancer (location)
YES
NO
________________________________________
YES
NO
________________________________________
Overactive___Underactive___ Treatment______
________________________________________
n.
Seizures
YES
NO
________________________________________
o.
Blood clots in legs
YES
NO
________________________________________
p.
Bleeding disorders or easy bruising YES
NO
________________________________________
q.
HIV positive or AIDS
YES
NO
________________________________________
r.
Other medical problems
YES
NO
________________________________________
m. Thyroid disease
7. Review of Systems: Have you recently experienced or are you currently experiencing: a. Unexplained weight loss
YES
NO
________________________________________
b. Skin rashes or sores
YES
NO
________________________________________
c. Headache
YES
NO
________________________________________
d. Sinus trouble or nosebleeds
YES
NO
________________________________________
Review of Systems, continued:
Date of Onset
e. Chest pain or irregular heart beat
YES
NO
________________________________________
f. Shortness of breath or cough
YES
NO
________________________________________
g. Muscle aches, joint pain, swelling
YES
NO
________________________________________
h. Muscle weakness
YES
NO
________________________________________
i. Blurred or double vision
YES
NO
________________________________________
j. Memory loss or confusion
YES
NO
________________________________________
k. Excessive urination or thirst
YES
NO
________________________________________
l. Easy bruising or bleeding
YES
NO
________________________________________
m. Depression or mood changes
YES
NO
________________________________________
8. Please list all medications you are currently taking. Include prescription and non prescription medicines. If you brought a separate list of your medications, please notify us so we can make a copy for our records: ___________________ ___________________ ___________________ ___________________
9.
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
Do you take aspirin or any blood thinners?
YES NO
If yes, what are they?_______________________________
10. Please list all vitamins or "natural" products you take: ___________________________________________________ 11. Do you smoke?
YES
NO
If yes, ____ packs of cigarettes/day
12. Do you drink alcohol?
YES
NO
If yes, ____ drinks/week
13. Have you ever had surgery on your eyelids or face? If yes, please give date and operation: ___________________
___________________
___________________
___________________
14. Please list all other operations you have had. Include the approximate date: ___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
15. Have you ever had a problem with or complication from anesthesia? YES
NO
16. Has your dentist ever had difficulty getting your mouth numb enough to perform routine dental work? YES NO 17. Have you ever had problems with or surgery on your eyes? Amblyopia__________ Cataract____________ Retinal problems_____________ Cataract surgery_______________
Laser treatment______________________
Glaucoma______________ Other ___________________
18. Do you have mitral valve prolapse? YES NO If yes, do you take antibiotics before going to the dentist? YES NO 19. Do you have any artificial joints (e.g. knee, hip) or other foreign material implanted in your body? If yes, please describe: __________________________________________________________________________________________________ 20. Do you now or have you ever used illicit drugs? YES NO 21. What is your current height? ____feet ____inches
22. What is your current weight? ______ pounds
22. Significant family medical history: Mother____________________________________________ Father______________________________________________ Siblings___________________________________________ I attest that the information provided above is correct to the best of my knowledge____________________________________ Patient signature/date Reviewed by ___________________________________
Date__________
Are you allergic to any medications? YES NO If yes, what are they? _________________________________ _____________________________________________________________ If yes, describe your reaction (s) _________________________________________________________________
6. Medical History: Have you ever had: a.
Diabetes mellitus
Date of Onset YES
NO
________________________________________
Diet control ___ Oral agents ___ Insulin ___ b.
Heart attack
YES
NO
________________________________________
Angina or chest pain
YES
NO
________________________________________
Heart failure
YES
NO
________________________________________
Irregular heart beat
YES
NO
________________________________________
c.
High blood pressure
YES
NO
________________________________________
d.
Stroke or "mini stroke"
YES
NO
________________________________________
e.
Anemia
YES
NO
________________________________________
f
Asthma, emphysema, tuberculosis YES
NO
________________________________________
g.
Liver disease, hepatitis, jaundice
YES
NO
________________________________________
h.
Stomach ulcers
YES
NO
________________________________________
i.
Kidney disease or stones
YES
NO
________________________________________
j.
Arthritis (if yes, specify type)
YES
NO
________________________________________
k.
Skin cancer
YES
NO
________________________________________
l.
Other types of cancer (location)
YES
NO
________________________________________
YES
NO
________________________________________
Overactive___Underactive___ Treatment______
________________________________________
n.
Seizures
YES
NO
________________________________________
o.
Blood clots in legs
YES
NO
________________________________________
p.
Bleeding disorders or easy bruising YES
NO
________________________________________
q.
HIV positive or AIDS
YES
NO
________________________________________
r.
Other medical problems
YES
NO
________________________________________
m. Thyroid disease
7. Review of Systems: Have you recently experienced or are you currently experiencing: a. Unexplained weight loss
YES
NO
________________________________________
b. Skin rashes or sores
YES
NO
________________________________________
c. Headache
YES
NO
________________________________________
d. Sinus trouble or nosebleeds
YES
NO
________________________________________
Review of Systems, continued:
Date of Onset
e. Chest pain or irregular heart beat
YES
NO
________________________________________
f. Shortness of breath or cough
YES
NO
________________________________________
g. Muscle aches, joint pain, swelling
YES
NO
________________________________________
h. Muscle weakness
YES
NO
________________________________________
i. Blurred or double vision
YES
NO
________________________________________
j. Memory loss or confusion
YES
NO
________________________________________
k. Excessive urination or thirst
YES
NO
________________________________________
l. Easy bruising or bleeding
YES
NO
________________________________________
m. Depression or mood changes
YES
NO
________________________________________
8. Please list all medications you are currently taking. Include prescription and non prescription medicines. If you brought a separate list of your medications, please notify us so we can make a copy for our records: ___________________ ___________________ ___________________ ___________________
9.
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
Do you take aspirin or any blood thinners?
YES NO
If yes, what are they?_______________________________
10. Please list all vitamins or "natural" products you take: ___________________________________________________ 11. Do you smoke?
YES
NO
If yes, ____ packs of cigarettes/day
12. Do you drink alcohol?
YES
NO
If yes, ____ drinks/week
13. Have you ever had surgery on your eyelids or face? If yes, please give date and operation: ___________________
___________________
___________________
___________________
14. Please list all other operations you have had. Include the approximate date: ___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
15. Have you ever had a problem with or complication from anesthesia? YES
NO
16. Has your dentist ever had difficulty getting your mouth numb enough to perform routine dental work? YES NO 17. Have you ever had problems with or surgery on your eyes? Amblyopia__________ Cataract____________ Retinal problems_____________ Cataract surgery_______________
Laser treatment______________________
Glaucoma______________ Other ___________________
18. Do you have mitral valve prolapse? YES NO If yes, do you take antibiotics before going to the dentist? YES NO 19. Do you have any artificial joints (e.g. knee, hip) or other foreign material implanted in your body? If yes, please describe: __________________________________________________________________________________________________ 20. Do you now or have you ever used illicit drugs? YES NO 21. What is your current height? ____feet ____inches
22. What is your current weight? ______ pounds
22. Significant family medical history: Mother____________________________________________ Father______________________________________________ Siblings___________________________________________ I attest that the information provided above is correct to the best of my knowledge____________________________________ Patient signature/date Reviewed by ___________________________________
Date__________
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