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Medical History

Patient Name

Contact Information



Pregnant
Trying to get pregnant?
Nursing
Taking oral contraceptives?


Penicillin or other antibiotics
Local anesthetics
Sulfa drugs



Choose the most appropriate number for each situation and total your score. How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired?


0 = would never doze

1 = slight chance of dozing

2 = moderate chance of dozing

3 = high chance of dozing


Sitting and reading


Watching TV


Sitting, inactive in a public place (like a theatre or a meeting)


As a passenger in a car for an hour without a break


Lying down to rest in the afternoon when circumstances permit


Sitting and talking to someone


Sitting quietly after a lunch without alcohol


In a car, while stopped for a few minutes in the traffic

General History












Itching
Rash
Ulcers
Pigmentation
Lack or loss of body hair
History of Shingles

Varicose veins
Swollen/painful joints
Muscle weakness/pain
Bone deformity/fractures
Prosthetic joints

Double vision
Blurred vision
Drooping eyelids
Glaucoma

Earache
Hearing loss
Frequent nosebleed
Sinusitis
Frequent sore throat
Hoarseness
Jaw joint pain

Cough
Blood in sputum
Emphysema
Wheezing, asthma
Tuberculosis or exposure to TB
Lung transplant

Shortness of breath
Pain, pressure in chest
Swelling of ankles
High/low blood pressure
Rheumatic or scarlet fever
Heart murmur
History of heart attack
Prosthetic valve
Pacemaker
Open heart surgery
Heart transplant

Difficulty swallowing
Abdominal pain, ulcers
Heartburn
Hepatitis, jaundice
Liver disease

Difficulty/pain on urination
Blood in urine
Excessive urination
Kidney infections
Urinary tract infections
Sexually transmitted disease

Thyroid issues
Weight change
Diabetes
Excessive thirst

Frequent headaches
Dizziness, fainting
Epilepsy
Neuritis/neuralgia
Parasthesia/numbness
Paralysis

Nervousness
Anxiety
Depression
Nervous breakdown
Bi-polar disorder







Prolia (denosumab)
Didronel (etidronate)
Bonefos (sodium clodronate)
Skelid (tiludronate)
Nerixia (neridronate)
Fosamax (alendronate)
Actonel (risedronate)
Boniva (ibandronate)
Aredia (pamidronate)
Zometa (zoledronic acid)
Reclast (zoledronic acid)



Three/four
Twice a year
Yearly
As needed


Diabetes
High blood pressure
Heart problems
Cancer
Seizures
Mental disorder



Cigarettes
Cigars
Chewing tobacco
Other


Occasionally
Socially
Frequently
Daily


Occasionally
Socially
Frequently
Daily


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