Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
COMPREHENSIVE MEDICAL HISTORY First and Last Name______________________________Birth Date ______/_______/______ (please print) month day year Allergies No Known Allergies Iodine Plastic Antibiotics Latex Sedatives Aspirin Local Anesthetics Sleeping Pills Barbiturates Metals Sulfa Drugs Codeine Penicillin Tetracycline Current Medications Medicine Dosage/Frequency Reason Medical History Medical Condition Never/Current/Past Acid Reflux Anemia Arteriosclerosis Arthritis Asthma Autoimmune Disorder Bleeding Easily Blood Pressure-High Blood Pressure-Low Bruising Easily Cancer Chemotherapy Chronic Fatigue Notes Medical Condition Never/Current/Past Hepatitis Hypoglycemia Immune System Disorder Ischemic Heart Disease Kidney Problems Liver Disease Meniere’s Disease Mitral Valve Prolapse Multiple Sclerosis Muscular Dystrophy Mood Disorder Nasal Allergies Neuralgia Notes Chronic Pain COPD CPAP/BiPAP Depression Diabetes Difficulty Sleeping Dizziness Emphysema Epilepsy Fibromyalgia Glaucoma Gout Heart Attack Osteoarthritis Osteoporosis Parkinson’s Disease Pregnancy Psychiatric Care Radiation Treatment Rheumatic Fever Rheumatoid Arthritis Sinus Problems Sleep Apnea Snoring Stroke Heart Disorder Heart Murmur Heart Pacemaker Thyroid disorder Tuberculosis Tumors Urinary Disorders Heart Valve Replacement Hemophilia Tendency for Ear Infections Prior Orthodontic Treatment Please list any additional Medical Conditions: Confidential Medical History: Recreational Drug Use HIV/AIDS I agree that the information provided above is to the best of my knowledge. Name__________________________________________________ Date_________________ (Patient’s Signature)