Page 21 - Private Information Guide

MEDICAL HISTORY AND ALLERGIES

MEDICAL HISTORY – Please check all that apply

n n No known medical conditions n n Diabetes/Insulin Dependent n n Seizure Disorder
n n Abnormal EKG n n Eye Surgery n n Sickle Cell Anemia

n n Alzheimer’s n n Glaucoma n n Stroke/CYA/TIA
n n Angina n n Hearing Impaired n n UTI

n n Asthma/Emphysema n n Heart Valve Prosthesis n n Vision Impaired
n n Bleeding Disorder n n Hemodialysis n n

n n CABG n n Hemolytic Anemia n n
n n Cancer n n Hypertension n n

n n Cardiac Dysrhythmia n n Leukemia n n
n n Cataracts n n LVAD n n

n n CHF n n Myasthenia Gravis n n
n n Clotting Disorder n n Myocardial Infarct n n

n n COPD n n Pacemaker/Defib n n
n n Coronary Bypass Stent n n Pneumonia n n

n n Dementia n n Renal Failure n n

ALLERGIES – Please check all that apply

n n No known allergies n n Insect Stings n n
n n Aspirin n n Latex n n

n n Barbiturates n n Lidocaine n n
n n Codeine n n Morphine n n

n n Demerol n n Novocaine n n
n n Environmental n n Penicillin n n

n n Horse Serum n n X-Rays/Dyes n n

RECENT SURGERIES

Dates Procedures

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