ANSWER ALL QUESTIONS by circling Yes (Y) or No (N) All responses are kept confidential!
G. Insulin or Oral Anti-Diabetic drugs? . Y N
H. Digitalis, Inderal, Nitroglycerin or other heart drugs. Y N
Are you taking or have you ever taken
Bisphosphonate for osteoporosis, multiple myeloma or
4. Are you now under a physician’s care for
other cancers (Fosamax, Actonel, Boniva, Aredia, Zometa) ? . Y N ever had any serious illnesses, any and all medications taken, including
operations or hospitalizations? If so, describe: . Y N
prescription medications, diet drugs, over-the-counter
mediations, herbal or holistic remedies, vitamins or
7. DO YOU HAVE OR HAVE YOU EVER HAD:
________________________________________________
A. Rheumatic Fever or Rheumatic Heart Disease? . Y N
________________________________________________
C. Cardiovascular Disease (Heart Attack, Heart
Trouble, Heart Murmur, Coronary Artery Disease,
9. ARE YOU ALLERGIC TO OR HAVE YOU HAD AN
Angina, High Blood Pressure, Stroke, Palpitations,
ADVERSE REACTION TO:
A. Local Anesthesia (Novocain, etc.)? . Y N
D. Lung Disease (Asthma, Emphysema, Chronic
B. Penicillin or other antibiotics? . Y N
Cough, Bronchitis, Pneumonia, Tuberculosis,
E. Seizures, Convulsions, Epilepsy, Fainting or
G. Other allergies or reactions? Please, list . Y N
F. Bleeding Disorder, Anemia, Bleeding Tendency,
Blood Transfusion? Do you bruise easily? . Y N
G. Liver Disease (Jaundice, Hepatitis)? . Y N
11. Is there any past history of Alcohol or Chemical
Dependency or Emotional Disorder that may affect
12. Have you or an immediate family member had any
problem associated with intravenous anesthesia? . Y N
13. Do you have any other disease, condition or
O. Implants placed anywhere in your body
problem not listed above that you think the doctor
(Heart Valve, Pacemaker, Hip, Knee)? . Y N
O. Radiation (X-ray) treatment for Cancer? . Y N
14. Do you wish to talk to the doctor privately
P. Clicking or popping of jaw joint, pain near ear,
difficulty opening mouth, grind or clench teeth? . Y N
15. FOR WOMEN ONLY
R. Any disease, drug or transplant operation
A. Are you Pregnant, or is there any chance
that has depressed your immune system (HIV, etc)?.Y N
8. ARE YOU USING ANY OF THE FOLLOWING:
C. If you are using Oral Contraceptives, it is important
that you understand that antibiotics (and some other
medications) may interfere with the effectiveness of oral
C. Aspirin or drugs such as Motrin, Aleve, Ibuprofen? . Y N
contraceptives. Therefore, you will need to use
D. High Blood Pressure medications? . Y N
mechanical forms of birth control for one complete cycle
of birth control pills, after the course of antibiotics or
cation is completed. Please consult with your
I understand the importance of a truthful Health History to assist the doctor in providing the best care possible. I have had the opportunity to discuss my Heath History with my doctor.
Rx3 Drug List Level One – Lowest copayment for low-cost generic drugs. Level Two – Higher copayment for higher cost brand-name drugs. Level Three – Highest copayment for higher cost drugs. These drugs may have generic or brand-name alternatives in Levels One or Two. Listed below in alphabetical order are commonly prescribed drugs for each level. This is not a complete list. I
What's in a Good Medical Kit? Howard Donner, MD Organizing medical equipment for an expedition requires an enormous amount ofplanning and forethought. No matter how much equipment is hauled in, onecannot possibly prepare for every eventuality. What should one take? There is a wide range of opinions, from "nothing but atriangular bandage and Swiss army knife" to a collection that would
Port Royal Oral Surgery, P.A.