MEDICAL DATA SHEET

DATE:_____________________ Record No. ________________
1. NAME: _____________________________________________ RACE: _______ SEX: M F AGE: _____________
Last first middle
OCCUPATION: _______________________________________________________________________________
2. REASON FOR THIS OFFICE VISIT: ___________________________________________________________________
Injury related? Yes No If yes, date: / /
3. LIST OF ALL MEDICATIONS (dose/mg ,how often taken; also include over-the-counter medications, sprays, or inhalers):
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4. SURGERY, HOSPITALIZATIONS, ENDOSCOPIES, SERIOUS INJURIES, or RADIATION:
Date brief description where? doctor
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5. ALLERGIES: (or intolerance) medication or other; please, give a brief description, such as rash, swelling, hives, anaphylaxis, nausea
______________________________________________________________________________________________
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6. DO YOU HAVE ANY OF THE FOLLOWING CONDITIONS OR PROBLEMS? (please, check Yes or No)
Yes No Yes No Yes No Yes No
heart disease            â–¡ â–¡     reaction to anesthesia â–¡ â–¡         blood disorder        â–¡ â–¡         loud noise exposure â–¡ â–¡        high blood pressure â–¡ â–¡  
seizures                      â–¡ â–¡     ulcers                              â–¡ â–¡         hearing loss            â–¡ â–¡         cancer                          â–¡ â–¡        nervous illness          â–¡ â–¡
liver disease              â–¡ â–¡      hay fever                         â–¡ â–¡         diabetes                   â–¡ â–¡         alcoholism                  â–¡ â–¡        high cholesterol         â–¡ â–¡
asthma                       â–¡ â–¡      kidney disease              â–¡ â–¡         high triglycerides    â–¡ â–¡         recent cough               â–¡ â–¡       stroke                           â–¡ â–¡
emphysema              â–¡ â–¡      blood clots                      â–¡ â–¡         thyroid disease       â–¡ â–¡         chronic bronchitis      â–¡ â–¡       bleeding tendency     â–¡ â–¡
other(specify):            â–¡ â–¡
 
7. HABITS: Amount of alcohol consumed per week ____________________
                        Tobacco products/cigarettes per day: _____________________
 
8. FAMILY HISTORY (any blood relatives with these conditions?) Please circle
Bleeding tendency     reaction to anesthesia diabetes cancer asthma
Heart disease blood disorder hayfever stroke seizure
Sickle cell high blood pressure tuberculosis hearing loss
Other: (specify)