Name: _________________________________Date: ______________Age: __________ PAST MEDICAL HISTORY YEAR ILLNESSES
________ ( ) Heart trouble (angina__) (heart attack ___) (Heart failure ___) (Heart murmur __) (valve
________ ( ) High blood pressure ________ ( ) Stroke ________ ( ) Ulcers (stomach ___) (duodenal___) (colon___) ________ ( ) Diabetes (high blood sugar) ________ ( ) Liver disease (hepatitis___) (A___) (B___) (Cirrhosis ___) Other______________________________ ________ ( ) Kidney disease (stones ___) (infections ___) other ____________ ________ ( ) Lung disease (emphysema ___)(TB___)(chronic bronchitis ___)(cancer___)
(frequent pneumonia___)(asthma___)Other_______________________
________ ( ) Blood disorders (anemia___) (leukemia ___) (bleeding tendency ___) Other _____________________________________________ ________ ( ) Eye disease (glaucoma___) Other_______________________ ________ ( ) Arthritis (degenerative___) (rheumatoid___) (gout ___)Other___________ ________ ( ) Cancer, Type ______________________________________ ________ ( ) Psychological difficulties (depression___) (psychosis ___) )Other________ ________ ( ) Other major illness_____________________________________________ ________ ( ) No major illnesses YEAR SURGERIES
________ ( ) Hysterectomy (total___) ( partial___) ________ ( ) Biopsy (result & type__________________________) ________ ( ) Fractures explain_________________________________________ ________ ( ) Other _________________________________________________
MAJOR INJURIES/ ACCIDENTES MAYORES ( ) Auto or cycle accidents:________________________________________________ ( ) NO MAJOR INJURIES HOSPITALIZATIONS:__________________________________________________
MEDICATIONS/MEDICINAS (Names & Dosages, if you have more please list on the back of the page.) ( ) ________________________________________________________________ ( ) ________________________________________________________________ ( ) ________________________________________________________________ ( ) ________________________________________________________________ ( ) Birth Control Pill __________________________________________________ ALLERGIES Describe Reaction: ( ) Penicillin (rash___) (breathing problems___) (required hospitalization___) (nausea/vomiting__)
(rash___) (breathing problems___) (required hospitalization___) (nausea/vomiting__)
( ) Keflex (rash___) (breathing problems___) (required hospitalization___) (nausea/vomiting__) ( ) Codeine (rash___) (breathing problems___) (required hospitalization___) (nausea/vomiting__) ( ) Other ________________________________________________________ ( ) None ________________________________________________________ FAMILY MEDICAL HISTORY/HISTORIA MEDICA FAMILIAR MOTHER: ( ) Alive & well ( ) Alive but suffers with:________________ Age____ ( ) Deceased / Cause:________________________ Age of death ________ FATHER: ( ) Alive & well ( ) Alive but suffers with:________________ Age____ ( ) Deceased / Cause:________________________ Age of death ________ SIBLINGS: ( ) Alive & well ( ) Alive but suffers with:________________ Age____ ( ) Deceased / Cause:________________________ Age of death ________ Members of my family: (brothers, sisters, grandparents, aunts, uncles) suffer from the following: ( ) Stroke
( ) Diabetes ( ) Back problems ( ) Heart trouble
SOCIAL HISTORY/HISTORIA SOCIAL 1. Married ___, Separated ___, Divorced ___, Widow-Widower____, Single______ No. of children at home ______ No. of children away ______ 2. I work as/ am retired from______________________________________________________ 3. I drink alcohol: None____ Daily____ Socially______ Beer_____ Wine_____ “Hard drinks”_______ I drink too much_______________________________ Others think I drink too much______ 4. I smoke: None____ Cigarettes_____ Pipe________ Cigars____
I smoke_____ packs______ a day, for_____ years.
Non-Preferred EDO Preferred Brands ($$$) Alternatives ($ or $$) * Preferred Drug List Dear Member: Please review this Preferred Drug List (PDL) with your physician at the time he or she writes your Formulary Disclaimer: prescription. This PDL, which includes both brand Please be sure your prescription drug benefit is offered and generic medications, is not a c
DIFFERENTIAL DIAGNOSIS OF ACUTE AND CHRONIC SYMPTOMATIC ORAL ULCERATIONS Acute and chronic ulcerations represent the most common symptomatic mucosal pathoses encountered by oral health care practitioners. Every clinician should have an organized approach to these problems which will be encountered frequently. The first step in all cases should be to divide and conquer. The ulcerations
General Medical Information 
