7137 Dublin Blvd # A, Dublin, CA 94568
Health History

Fill Out The Form Belows

Are you taking any prescription medication, over the counter medications or herbal medicine?
Do you or have you used bisphosphonate medication (Fosamax, Actonel, Boniva, Skelled, Didronel, Aredia, Zometa or Bonefos?

Do you have or did ever have any of the following?

High blood pressure(Required)
Angina or heart attack(Required)
Chest pain or physical exertion(Required)
Coronary artery blockage or treatment (bypass, stent, etc.)(Required)
Heart valve problem or replacement(Required)
Heart murmur(Required)
Heart disease, problem or treatment(Required)
Rheumatic fever(Required)
Past use of Fen-Phen(Required)
Irregular heart beat or pace maker(Required)
Difficulty breathing when lying down(Required)
Stroke(Required)
Low blood pressure(Required)

Respiratory Health

Asthma(Required)
Emphysema or respiratory problems(Required)
Chronic Sinus problem(Required)
Tuberculosis or persistent cough(Required)

Endocrine/ Blood/ Immune Health

Diabetes(Required)
Frequent thirst of frequent urination(Required)
Thyroid problems(Required)
Abnormal bleeding, bruise easily(Required)
Hemophilia(Required)
Anemia/blood disease(Required)
Cancer(Required)
Radiation Therapy/ Chemotherapy(Required)
HIV infections/ AIDS(Required)
Cold sores/ Canker sores(Required)
Organ transplant(Required)
Blood transfusion(Required)
Joint replacement(Required)
Arthritis(Required)
Osteoporosis(Required)
Fainting spells or dizziness(Required)
Seizures(Required)
Numbness or muscle weakness(Required)
Multiple sclerosis(Required)
Dementia/ Alzheimer’s disease(Required)
Anxiety/ Nervousness(Required)
Mental Health treatment(Required)

Gastro- Intestinal/ Genitor- Urinary Health

Hepatitis (A, B, C or other)(Required)
Liver disease/ Dialysis(Required)
Stomach trouble/ Ulcers(Required)

Medication Allergies and Other Allergies

Penicillin or other antibiotic’s(Required)
Sulfa drugs(Required)
Dental anesthetic(Required)
Aspirin(Required)
Codeine/ Narcotics(Required)
Iodine(Required)
Latex products(Required)
Metals/Nickels/ Jewelry(Required)

FEMALE ONLY

Are you pregnant?
Are you nursing now?
Do you take birth control pills?

Social

Do you use Tabaco?(Required)
Do you use alcohol?(Required)
Do you use recreational drugs?(Required)
I hereby that I have read the foreign and filled out this questionnaire completely. I have advised you of all medical problems of which I am aware. I further certify that I, the unsigned, consent to the performing of x-rays and examination.
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Clear Signature
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