Medical history update - GalliaFamilyDental Patient Information* Patient Name: (Required) Male Female Home Address: City: State: Zip: Primary Phone: homecell Secondary Phone: homecellotherOk to leave message?YesNoE-mail: Medical HistoryAre you currently being treated by a physician? Yes NoReason: Physician: Last Visit: Phone: Do you have any allergies/sensitivities to medications or latex? Yes NoIf yes, please list: Are you currently taking any prescription or over-the-counter medications? Yes NoPlease list, with dosage: Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)? Yes NoHave you had any serious illnesses or operations? If yes, describe: Have you ever had a blood transfusion? Yes NoIf yes, give approximate dates: (Women) Are you pregnant? Yes NoNursing? Yes NoTaking birth control pills? Yes NoCheck if you have or have ever had any of the following: AIDS Arthritis, Rheumatism Artificial Heart Valves Artificial Joints Asthma Back Problems Blood Disease Cancer Chemical Dependency Chemotherapy Circulatory Problems Cortisone Treatments Cough, Persistent Coughing Blood Diabetes Epilepsy Fainting Glaucoma Headaches Heart Murmur Heart Problems Hemophilia Hepatitis High Blood Pressure HIV/AIDS Jaw Pain Kidney Disease Liver Disease Mitral Valve Prolapse Pacemaker Radiation Treatment Respiratory Disease Rheumatic Fever Scarlet Fever Shortness of Breath Skin Rash Stroke Swelling of Feet or Ankles Thyroid Problems Tobacco Habit Tonsilitis Tuberculosis Ulcer Venereal Disease (STD)AuthorizationI understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status.Submitted by: Date: Security Measuregoogle recaptcha