Microsoft word - medical information forms

Dr. Howard F. Cooke, D.M.D., M.S.
My Medication Information
Patient’s Name:________________________________________ Today’s Date ______________________ Primary Care Physician’s Name ___________________________ Phone Number ______________________ Pharmacy (with location) _________________________________ Phone Number _____________________ Other _____________________________________________________________ MEDICATIONS: Are you allergic to, sensitive to, or had a bad reaction to: (Circle Yes or No) Local Anesthetic (Novocaine, etc.) Yes No List any other medications you are allergic to: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ARE YOU USING OR TAKING ANY OF THE FOLLOWING? (Circle Yes or No) Other Heart Medicine ___________________ Tranquilizers (Valium, Anti-Depressants) Yes Antihistamines or Decongestants (Seldane) Aspirin or Ibuprofen (Motrin, Naprosyn, etc.) Digitalis, Inderal, Nitroglycerin, Calcium Channel Yes No If yes, how much daily?___________________ LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING: Prescriptions and over-the-counter medications (ie. aspirins, antacids), herbal supplements (ie. ginseng, gingko). Include all medications taken as needed (ie. nitroglycerin, inhalers, and allergy medications). Patient’s Name_______________________________________________________________ Are you now under a physician’s care, or have you been during the past 5 years, for a particular condition? Yes No If so, what for?_____________________________________________________________________________________________ Have you had any serious illness, operations, or hospitalizations during the past five years? If so, describe _____________________________________________________________________________________________ Have you had any implant surgery done? List types & date _______________________________________________ Have you ever taken any street/recreational drugs? Have you ever taken any form of Redux or Fen/Phen? Do you take/have you taken radiation or chemo for cancer? Are you pregnant, nursing a child, or planning pregnancy? DO YOU HAVE OR EVER BEEN DIAGNOSED WITH? (Circle Yes or No)Heart Attack/Heart Surgery I allow you to give my clinical information to, or answer questions from: (please list all that apply) Name of Person(s) Relationship to patient (ie. spouse, parent, child, etc.) I certify that I have read and understand the questions above and the above information is current and correct. I will not hold my surgeon or any of their staff responsible for any errors or omissions that I have made in the completion of this form. ___________________________________________________________________ __________________________________ Patient/Legal ___________________________________________________________________ __________________________________ Clinical

Source: http://www.drhcooke.com/forms/medical-info.pdf