OFFICE: (813) 931-0700 FAX: (813) 933-8009

Patient Medical History

If you would like to print and fill out a PDF version of this form please click here. Otherwise fill out the form below.

List any surgery you've had in the past
Use the plus sign to the right to add more.
Have you ever had problems with anesthesia?(Required)
List any medications or drugs you have taken within the past year.(Required)
Medication
Dosage
How Often
 
Use the plus sign to the right to add more.
Are you in pain management?(Required)
Have you had an ALLERGIC or unfavorable reaction to any food, medication, or drugs?(Required)
Please list any allergic or unfavorable reactions
Use the plus sign to the right to add more.

Have you had or do you currently have any of the following?

Cancer?(Required)
Osteoporosis / Osteopenia?(Required)
Damaged heart valves/mitral valve prolapse?(Required)
Heart murmur?(Required)
High blood pressure?(Required)
Chest pain, angina?(Required)
Heart attack(s)?(Required)
Bronchitis, chronic cough, pneumonia?(Required)
Asthma, hay fever, or sinus problems?(Required)
Tuberculosis?(Required)
Difficulty breathing, emphysema?(Required)
Any other lung trouble?(Required)
Do you smoke?(Required)
Bruise easily?(Required)
Bleeding tendency (abnormal bleed)?(Required)
Jaundice, hepatitis or liver disease?(Required)
Frequent headaches?(Required)
Fainting spells?(Required)
Convulsions, epilepsy?(Required)
Stroke?(Required)
Thyroid trouble?(Required)
Diabetes?(Required)
Frequent thirst or urination?(Required)
Kidney trouble?(Required)
Are you on dialysis?(Required)
Swollen ankles, arthritis, or joint disease?(Required)
Stomach ulcers?(Required)
Contagious diseases?(Required)
Sexually transmitted diseases?(Required)
Herbals or Supplements?(Required)
Acne, facial scarring, skin blemishes?(Required)
Problems of the immune system?(Required)
Recent weight loss?(Required)
Mental health problems/psychiatric treatment?(Required)
Drugs (marijuana, cocaine)?(Required)
Alcoholic beverages?(Required)
Eye disease/glaucoma?(Required)
Radiation therapy/chemotherapy?(Required)
Blood transfusion?(Required)
Pain or clicking of jaws when eating?(Required)
Malignant hyperthermia?(Required)
Are you pregnant?(Required)
TMJ problems?(Required)
Snoring or sleep disturbance?(Required)
Do you have any other medical or health problems which have not been mentioned above?(Required)
Fees and Payments(Required)