Patient Name

Today's Date

Do you have or have you had any of the following problems or disorders?

High blood pressure

Yes

No

Low blood pressure

Yes

No

Heart murmur or mitral valve prolapse

Yes

No

Any type of heart condition/attack/surgery

Yes

No

If yes, describe

Prolonged or excessive bleeding

Yes

No

Easy bruising

Yes

No

Anemia

Yes

No

Other blood or circulation problems

Yes

No

Artificial joints

Yes

No

Have you ever had a reaction or allergy to any drugs, pills, anesthetics, or medicines?

Yes

No

If yes, which ones?

If yes, describe

Drug abuse

Yes

No

Treatment for drug abuse or alcoholism

Yes

No

Treatment for an emotional disorder

Yes

No

Diabetes

Yes

No

History of diabetes in family

Yes

No

Hepatitis, jaundice or other liver diseases

Yes

No

Stomach trouble, colitis, or ulcers

Yes

No

Fainting spells, dizziness, or seizures

Yes

No

Sinus problems

Yes

No

AIDS or HIV

Yes

No

Immunological problems

Yes

No

Mhritis, rheumatism, or other joint problems

Yes

No

Respiratory problems, emphysema, bronchitis

Yes

No

Tuberculosis Kidney or bladder problems or infections

Yes

No

Asthma

Yes

No

Sexually transmitted diseases

Yes

No

Thyroid problems

Yes

No

Do you consider yourself a nervous person

Yes

No

Are you under high stress

Yes

No

Glaucoma or other eye diseases

Yes

No

Do you wear contact lenses

Yes

No

Skin lesions or diseases

Yes

No

Treatment for any tumors, growths, or cancer

Yes

No

If yes, describe

Do you smoke? If so, how much, and for how long?

Did you ever smoke? If so, how much?

When did you stop smoking?

Are you under a physician's care now?

Yes

No

In the past 2 years?

Yes

No

Have you been hospitalized in the past 5 yrs?

Yes

No

If so, for what?

Date of last physical exam or checkup

Findings

Multiple Radio

Good

Fair

Poor

Don't Know

What pills, drugs, or medicines do you take on a regular basis (prescribed over the counter, including vitamins or aspirin)?

What have you taken in the past that has worked well for pain?

for infection?

Do you eat a balanced diet?

Yes

No

How many alcoholic beverages in a day?

in a week?

For Women

Are you pregnant? If so, how many months?

Are you trying to become pregnant?

Yes

No

Are you going through or completed menopause?

Yes

No

Are you now taking birth control pills?

Yes

No

Do you know that antibiotics may cause birth control to be ineffective?

Yes

No

Is there anything else or anything special you think I should know about your medical history?

I certify that I have answered all questions to the best of my knowledge. I will not hold Dr. Nasr, Dr. Sáenz, or their staff responsible for any errors that I may have made in the completion of this form.

Patient Signature