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medical
alert for office use only:
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| Patient's
name:
Please indicate if any of the following questions pertain to your health and medical history. Treatment will not be denied based on a positive response to any of the questions. Treatment may be denied if questions are not answered. The success of therapy and our avoidance of complications (infections, drug reaction, toxicity, etc.) could be enhanced by your answering these questions. checkbox if yes |
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| Reaction or allergy to: | Hospitalization for illness or surgery Date and reason | |
| Sulfa | Penicillin | Tetracycline |
| Codeine | Aspirin/Ibuprofen | Sedative or sleeping pills |
| Dental anesthetic | Any other medication | Latex, foods or pollens |
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| Hepatitis | Jaundice (yellowing of skin) | Sexually transmitted disease(s) |
| Human immunodeficiency virus (HIV) | Scarlet fever | Rheumatic fever |
| Osteoporosis | Chest pains on mild exertion | Asthma |
| Glaucoma | Multiple sclerosis | Stroke |
| Arthritis | Epilepsy | Psychiatric treatment |
| Chemotherapy/Radiation | Heart trouble | Prostate problems (if male) |
| Artificial joints | Mitral valve prolapse | Anemia or blood disorders |
| Prolonged bleeding | Kidney disease | Thyroid/parathyroid disorder |
| Stomach or duodenal ulcer | Liver disease | Tuberculosis |
| Emphysema | Sinus problems | Diabetes |
| Hypoglycemia | High cholesterol | High blood pressure |
| Low blood pressure | Shortness of breath | Hives, skin rash, hay fever |
| Tension | Tumor or abnormal | |
| Female | Are you pregnant? | Taking birth control pill or hormones |
| Presently in menopause | Past menopause | |
| Please
explain if any of the above are answered yes: |
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| Are
you presently being treated for any illness? If yes, please explain: |
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| prescription
medications: Over The Counter Medication or Herbal supplements: For? For? For? For? |
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