Adult Medical History

Name:*
DOB:*
Address:*
E-mail:
Home Phone:
-
Cell Phone:
-
Texting Capable:
Work Phone:
-

Patient Medical History

Primary Physician:
Dr's Phone:
-
Date of Last Exam:
Have you ever been hospitalized for surgery or serious illness?*
Are you under medical treatment now?*
Are you taking any medication(s) including non-prescription?*
If Yes, please list any/all medication(s):
Have you ever taken FEN-PHEN/REDUX?*
Does you use tobacco?*
Do you use alcohol, cocaine or any other drugs?*
Do you wear contact lenses?*
Are you allergic to or had any reactions to the following?
Describe "Other":
Do you have a persistent cough(lasting more than 3 weeks) or throat clearing NOT associated with an illness*
Women Only:
Do You Have OR Have You Had:*
Condition(s) Comments:

Dental History

Check Those That Apply:*

By submitting this form, I certify I have read and understand the above information, to the best of my knowledge, the above questions have been accurately answered.  I understand providing incorrect information can be dangerous to my health.


Human Verification:

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