Drmariafecorpuzbato.com

Dr. Maria Fe Corpuz-Bato
MEDICAL HISTORY
Patient’s name ____________________________________________________________Date Form Completed____/_____/_____ Birth date______/______/______ Weight___________________________*Blood Pressure___________________
Instructions to the Patient:
Answer the following questions as completely and accurately as possible.
All information is CONFIDENTIAL. Please circle “yes” or “no” to al questions, and write your answers as appropriate.
1. Are you under the care of a physician at this time?.YES NO
If yes for what condition?____________________________________________________________________________
2. The name and address of my physician is:______________________________________________________________
3. My last physical examination was on: __________________________________________________________________
4. Has a physician treated you in the past six months?.YES NO
If yes, for what condition? ___________________________________________________________________________
5. Have you been hospitalized or have a serious illness within the last five years?.YES NO
If yes, please specify: ______________________________________________________________________________
6. Are you allergic or had any adverse reaction to any medicines, drugs, local anesthetics, LATEX or other substances?.YES NO
If yes, please specify: ______________________________________________________________________________
7. Do you have or have you had any of the following diseases/problems?
A.
Abnormal bleeding, bruise easily or require Artificial/Prosthetic Joint Replacement…………….……YES NO
a blood transfusion……………………………….YES NO
Q. Artificial/Damaged Heart Valves…………………….….YES NO
Angina/Chest Pain……………………………….YES NO
Cardiovascular (heart) Disease, Arteriosclerosis/ Coronary Asthma/ Lung/ Respiratory Condition……….YES NO
Occlusion…………………………………………….…… YES NO
Diabetes………………………………………….YES NO
Cancer/Chemo/Radiation Therapy………………….….YES NO
Emotional/ Mental Health Disorder……. ………YES NO
Congenital Heart Disease…………………………….….YES NO
Epilepsy/ Seizures/Convulsions……………….YES NO
Congestive Heart Failure…………….YES NO
G. Hepatitis/Jaundice/Cirrhosis, Liver Disease.….YES NO
Heart murmur………………………………………….….YES NO
High Blood Pressure…………………………….YES NO
W. Immune suppression or deficiency………………….…YES NO
HIV positive/AIDS……………………………….YES NO
Infective endocarditis……………………………….…….YES NO
Hives or skin rash…………………………….…YES NO
Mitral valve prolapse…………………………………….YES NO
Kidney/Renal Disease……………………………YES NO
Pacemaker………………………………………….…….YES NO
Sexually Transmitted Disease(s)…………….…YES NO
AA. Rheumatic heart disease…………………………….….YES NO
M. Stomach Ulcers………………………………….YES NO
Date:_______ YES NO
Thyroid Disease…………………………….….YES NO
Date:_______ YES NO
O. Tuberculosis………………………………………YES NO
Date:_______ YES NO

8. Have you had surgery or x-ray treatment for a tumor, growth or other condition of your head or neck?.YES NO
If yes, please list: _________________________________________________________________________________

HEALTH HISTORY
9. Are you taking any of the fol owing medications for osteoporosis or bone loss due to aging, Paget’s Disease, multiple myeloma or
any type of cancer………………………………………………………………………………………………………………………. YES NO
If yes, please check the appropriate medication below:
Etidronate (Didronel® or Didrocal® or CO Etidronate® or Gen-Etidronate®) Clodronate (Benefos® or Clasteon® or Ostac®)
10. Have you ever taken appetite suppressant drugs such as Dexfluramine, Fenfluramine, PhenFen, Pondimin or Redux?.YES NO
If yes, please list: _____________________________________________________________________________
11.*Please list any premedication, medications, pills or drugs which you are taking both prescription and nonprescription.

12. WOMEN ONLY: Are you pregnant?.YES NO
If yes, when is your expected due date? ____________________________________________________________
13. Do you have any other diseases, conditions, or problems not listed above?
If yes, please explain:………………………………………………………………………….………………………………………YES NO
I certify that I have read and understand the above. I acknowledge that I have answered these questions accurately and completely. I will not hold the
office of Dr. Maria Fe Corpuz-Bato responsible for any action taken or not taken because of errors I may have made when completing this form.
PATIENT SIGNATURE: _____________________________________________DATE SIGNED: ________/________/_______
(Parent or Guardian’s Signature if patient is a minor.)
HEALTH HISTORY

Source: http://drmariafecorpuzbato.com/files/42378806.pdf