Common use of Medical History Clause in Contracts

Medical History. Are you currently under the active care of a physician or do you have any present health issues? ☐ YES ☐ NO If yes, please explain: Do you need to pre-medicate with antibiotics for any heart or other conditions before dental treatment? ☐ YES ☐ NO Are you taking any prescription or over the counter medications (including ibuprofen, Diet supplements, etc.)? ☐ YES ☐ NO Please list each one: Are you pregnant or nursing? ☐ YES ☐ NO / Do you smoke? ☐ YES ☐ NO If so, how much daily? Are you allergic to (Please check all that apply): ☐ ASPIRIN ☐ CODEINE ☐ DENTAL ANESTHETICS ☐ ERYTHROMYCIN ☐ SULFITES ☐ LATEX ☐ PENICILLIN ☐ TETRACYCLINE ☐ ANY METALS ☐ OTHER: Do you drink alcohol? ☐YES ☐ NO , If so, how much daily? Please check all that apply: ☐ ARTHRITIS ☐ ARTIFICIAL BONES/ JOINTS/ VALVES ☐ ASTHMA ☐ BLODD TRANSFUSION ☐ CONGENITAL HEART DEFECT ☐ HIV/AIDS ☐ CANCER/CHEMOTHERAPY ☐ ULCERS ☐ HPV ☐ DIABETES ☐ EMPHYSEMA ☐ KIDNEY PROBLEMS ☐ FAINTING ☐ FREQUENT HEADACHES ☐ LIVER DISEASE ☐ HEART ATTACK ☐ HEART MURMUR ☐ LOW BLOOD PRESSURE ☐ HEART SURGERY ☐ HEPATITIS TYPE ☐ LUPUS ☐ HERPES/FEVER BLISTERS ☐ HIGH BLOOD PRESSURE ☐ MITRAL VALVE PROLAPSE ☐ PACEMAKER ☐ RADIATION TREATMENT ☐ RHEUMATIC/SCARLET FEVER ☐ SEIZURES ☐ SHINGLES ☐ SICKLE CELL DISEASE ☐ THYROID ☐ TUBERCOLOSIS Please list any significant medical condition(s) or surgeries you have had (not listed above): The information I have provided on this form is accurate and complete to the best of my knowledge, information and belief. I will notify the practice at the soonest practical moment of any changes in the information I have provided. In consideration of being accepted as a patient of the practice, I agree to abide by the terms and conditions of this patient application & practice management. SIGNATURE: DATE:

Medical History. Are you currently under the active care of a physician or do you have any present health issuesYes No Has your child’s medical history been normal/unremarkable? ☐ YES ☐ NO If yesno, please explain: Do you need to pre-medicate with antibiotics for Yes No Has your child received any heart or other conditions before dental treatment? ☐ YES ☐ NO Are you taking any prescription or over the counter medications (including ibuprofen, Diet supplements, etc.)? ☐ YES ☐ NO Please list each one: Are you pregnant or nursing? ☐ YES ☐ NO / Do you smoke? ☐ YES ☐ NO If so, how much daily? Are you allergic to (Please check all that apply): ☐ ASPIRIN ☐ CODEINE ☐ DENTAL ANESTHETICS ☐ ERYTHROMYCIN ☐ SULFITES ☐ LATEX ☐ PENICILLIN ☐ TETRACYCLINE ☐ ANY METALS ☐ OTHER: Do you drink alcohol? ☐YES ☐ NO , If so, how much dailymedical diagnoses? Please check all that applyspecify: ☐ ARTHRITIS ☐ ARTIFICIAL BONES/ JOINTS/ VALVES ☐ ASTHMA ☐ BLODD TRANSFUSION ☐ CONGENITAL HEART DEFECT ☐ HIVYes No Has your child had genetic testing? Yes No Has your child had an MRI? Yes No Has your child had an EEG? Yes No Frequent ear infections? Yes No Were ear tubes ever placed? Yes No Hearing problems? Yes No Vision problems? Yes No Headaches? Yes No Meningitis? Yes No Seizures? Yes No Asthma? Yes No Slow/AIDS ☐ CANCERfast growth? Yes No Head injury? Yes No Allergies? Yes No Hospitalizations? Describe below. Yes No Physical/CHEMOTHERAPY ☐ ULCERS ☐ HPV ☐ DIABETES ☐ EMPHYSEMA ☐ KIDNEY PROBLEMS ☐ FAINTING ☐ FREQUENT HEADACHES ☐ LIVER DISEASE ☐ HEART ATTACK ☐ HEART MURMUR ☐ LOW BLOOD PRESSURE ☐ HEART SURGERY ☐ HEPATITIS TYPE ☐ LUPUS ☐ HERPESSexual Abuse? If yes to any of the above, please describe: Has your child ever been hospitalized, had surgeries, or major illnesses? Age How long Reason What medications does your child currently take? (Include over-the-counter supplements) Name Dose Frequency Reason Describe your child’s sleep routine: Typical bed time: Typical wake time: Trouble falling asleep? Yes No Trouble staying asleep? Yes No Trouble waking up early? Yes No Any other sleep problems? Explain: Describe your child’s diet: Describe your child’s current level and type(s) of exercise: Mental Health History Has your child had previous neuropsychological testing? Yes No If Yes, where? When? Has your child had any additional testing (e.g., psychoeducational, speech/FEVER BLISTERS ☐ HIGH BLOOD PRESSURE ☐ MITRAL VALVE PROLAPSE ☐ PACEMAKER ☐ RADIATION TREATMENT ☐ RHEUMATIC/SCARLET FEVER ☐ SEIZURES ☐ SHINGLES ☐ SICKLE CELL DISEASE ☐ THYROID ☐ TUBERCOLOSIS Please list any significant medical condition(slanguage?) Yes No If Yes, where? When? *If you answered Yes to either of the above questions, please attach or surgeries you have had (not listed above): The information I have provided on this form is accurate and complete to the best of my knowledge, information and beliefotherwise provide report(s). I will notify the practice at the soonest practical moment of any changes Has your child received psychotherapy services or counseling in the information I have providedpast? Yes No Or in the past? Yes No If Yes: Name of provider: Dates: Is your child seeing a psychiatrist for medication? Yes No Name of Psychiatrist: Dates: Medication the Psychiatrist Prescribed: Is there any history of self-harm or suicidal thoughts, threats, or attempts? Please Explain: List any previous or current mental health diagnoses: Psychosocial Functioning Describe the child’s personality: What are your child’s non-academic strengths? What are your child’s non-academic weaknesses? How does the child spend his/her free time? In what community or extracurricular activities is your child involved? Any concerns about child’s social group/friends? Explain: Any concerns about substance use? Explain: Please place a mark next to behaviors that you believe your child exhibits to an excessive or exaggerated degree when compared to other children his or her age. In consideration Sleeping and Eating ❑ Nightmares ❑ Trouble falling asleep ❑ Trouble staying asleep in the morning ❑ Decreased need for sleep without getting tired ❑ Excessive snoring during sleep ❑ Eats Poorly ❑ Eats excessively Social Development ❑ Prefers to be alone ❑ Excessively shy or timid ❑ More interested in objects than people view ❑ Difficulty making friends ❑ Teased by other children ❑ Bullies other children ❑ Excessive daydreaming and fantasy life Motor Skills ❑ Poor fine motor coordination ❑ Poor gross motor coordination ❑ Generally “clumsy Other Problems ❑ Bladder control problems ❑ Poor bowel control (soils self) ❑ Any history of being accepted as motor/vocal tics ❑ Overreacts to noises ❑ Overreacts to touch ❑ Problems with taste or smell Behavior ❑ Stubborn ❑ Irritable, angry, or resentful ❑ Frequent tantrums ❑ Strikes out at others ❑ Throws or destroys things ❑ Lying ❑ Stealing ❑ Argues with Adults ❑ Low frustration threshold ❑ Daredevil behavior ❑ Runs away ❑ Needs a patient lot of the practicesupervision ❑ Doesn’t empathize with others ❑ Overly trusting of others ❑ Doesn’t appreciate humor ❑ Impulsive (does things without thinking) ❑ Poor sense of danger ❑ Skips school ❑ Seems depressed ❑ Cries frequently ❑ Excessively worried and anxious ❑ Overly preoccupied with details ❑ Overly attached to certain objects ❑ Not affected by negative consequences ❑ Drug use ❑ Alcohol use ❑ Sexual activity, I agree to abide behavior, or sexual talk ❑ Not sought out for friendship by the terms and conditions peers ❑ Difficulty seeing another person’s point of this patient application & practice management. SIGNATURE: DATE:view Family History

Medical History. Are Physician/Program Name Address Telephone Number Date of last Physical Exam Weight Height Have you currently under ever been hospitalized for a medical (physical) reason? [ ] yes [ ] no Date of Hospitalization What was the active care reason for your hospitalization? Have you ever had surgery? [ ] yes [ ] no Nature of a physician or do Surgery Hospital Date Please indicate if you have ever received any of the following testing; if not, please mark with “N/A”. Date Result (if known) and facility preformed at CT Scan (brain) MRI (brain) EEG Neuropsychological Testing Do you have any present health issuesof the following medical illnesses? ☐ YES ☐ NO If yesNo. Yes. Please provide further information AIDS/HIV Blood pressure problem Cancer Diabetes Epilepsy/seizures Gastrointestinal Head Injury (Head trauma Heart disease Kidney disease Liver disease Neurological disease (stroke, please explain: neuropathy, headaches etc.) Thyroid disease Musculoskeletal problems Sleep Apnea Other Do you need to precurrently have any of these physical symptoms? No Yes. Please provide further information. Bleeding or bruising Cardiac (heart) problem (heart-medicate with antibiotics for any heart or other conditions before dental treatment? ☐ YES ☐ NO Are you taking any prescription or over the counter medications (including ibuprofenracing, Diet supplementschest pain, etc.)? ☐ YES ☐ NO Please list each ) Diarrhea or constipation Dizziness, lightheadedness or fainting Feel cold or hot Headaches Muscle spasms or weakness Weight change Other EMERGENCY CONTACT Name: Relation: Phone number(s): Patient Signature: Date: Today's date: I I TAK Center for Mental Health HIPAA & Consent Primary Care Physician: Patient's last name: First: Middle Initial: Marital status (circle one): Single / Mar / Div / Sep / Wid Former name (if applicable): Birth date: Are you pregnant or nursing? ☐ YES ☐ NO / Do you smoke? ☐ YES ☐ NO If so, how much daily? Are you allergic to I I Age: Sex: OM □ F Street address: Home phone no.: Cell phone no.: ( ) ( ) P.O. box: City: State: ZIP Code: Race (Please check all that apply): ☐ ASPIRIN ☐ CODEINE ☐ DENTAL ANESTHETICS ☐ ERYTHROMYCIN ☐ SULFITES ☐ LATEX ☐ PENICILLIN ☐ TETRACYCLINE ☐ ANY METALS ☐ OTHER□ American Indian or Alaska Native □ Asian Ethnicity □ Hispanic or Latino □ Native Hawaiian or Other Pacific Islander □ Black or African American (check one): □ Not Hispanic or Latino □ White □ Hispanic □ Other Race Social Security No.: Do you drink alcohol? ☐YES ☐ NO ---- --- I E-mail Address: Preferred Pharmacy /Location: By signing below, If soI acknowledge the following: • I give TCMH (TAK Center for Mental Health) consent to access my prescription history, how much daily? Please check including all past prescribed medication, in order to verify future prescription refills. • I give TCMH consent to bill my insurance company for any fees related to services provided by their staff, perform reasonable and necessary medical examinations, testing and treatment at the discretion of its healthcare professionals based on their clinical judgment of my condition. • I give TCMH consent to bill me directly for any charges denied by my insurance company, and for any charges incurred in the event of lack of insurance coverage at the time of care. • I understand that apply: ☐ ARTHRITIS ☐ ARTIFICIAL BONES/ JOINTS/ VALVES ☐ ASTHMA ☐ BLODD TRANSFUSION ☐ CONGENITAL HEART DEFECT ☐ HIV/AIDS ☐ CANCER/CHEMOTHERAPY ☐ ULCERS ☐ HPV ☐ DIABETES ☐ EMPHYSEMA ☐ KIDNEY PROBLEMS ☐ FAINTING ☐ FREQUENT HEADACHES ☐ LIVER DISEASE ☐ HEART ATTACK ☐ HEART MURMUR ☐ LOW BLOOD PRESSURE ☐ HEART SURGERY ☐ HEPATITIS TYPE ☐ LUPUS ☐ HERPES/FEVER BLISTERS ☐ HIGH BLOOD PRESSURE ☐ MITRAL VALVE PROLAPSE ☐ PACEMAKER ☐ RADIATION TREATMENT ☐ RHEUMATIC/SCARLET FEVER ☐ SEIZURES ☐ SHINGLES ☐ SICKLE CELL DISEASE ☐ THYROID ☐ TUBERCOLOSIS Please list TCMH is not responsible for any significant medical condition(s) bills incurred by me for testing, imaging, or surgeries you have had (not services provided by outside facilities, including those services ordered by their staff. • I give TCMH consent to call, text, and/or email an appointment reminder to the phone number listed above): The information . I understand that there may be a voicemail left for me at this phone number. • I acknowledge that I have been given access to TCMH's Notice of Privacy Practices. • I authorize TCMH to discuss my health information with the following person(s): Name Telephone# Relation Name Telephone# Relation □ Self Only: Ifchecked, TCMH will not release your information to anyone except as outlined in our Notice of Privacy Practices. Please initial I release TAK Center for Mental Health (TCMH) from all responsibility and liability that may arise from this authorization. I may withdraw this authorization at any time by giving written notification to TCMH, provided that I do so in writing and to the extent that we have already disclosed the information in reliance on this form authorization. Patient Signature (or Guardian ifpatient is accurate and complete to under the best age of my knowledge, information and belief. I will notify the practice at the soonest practical moment of any changes in the information I have provided. In consideration of being accepted as a patient of the practice, I agree to abide by the terms and conditions of this patient application & practice management. SIGNATURE: DATE:18) Date

Medical History. Has your medical history been normal/unremarkable? Yes No If no, please explain: Have you received any medical diagnoses? Yes No Please explain: Circle All that Apply: Yes No Have you completed genetic testing? Yes No Have you had an MRI? Yes No Have you had an EEG? Yes No Frequent ear infections? Yes No Were ear tubes ever placed? Yes No Hearing problems? Yes No Vision problems? Yes No Headaches? Yes No Meningitis? Yes No Seizures? XxXxxxxxx Assessment and Psychological Services xxxxxxxxxxxxxxxx@xxxxxxxxxxxxxxxxxxxxxxxxxxxxxx.xxx 000-000-0000 Yes No Asthma? Yes No Slow/fast growth? Yes No Head injury? Yes No Allergies? Yes No Hospitalizations? Yes No Have you experienced anything you would call traumatic (physical, verbal, or emotional abuse; unwanted sexual experiences; accidents or other events)? Have you ever been hospitalized, had surgeries, or major illnesses? Age How long Reason What medications do you currently take? (Include over-the-counter supplements) Name Dose Frequency Reason Describe your sleep routine: Typical bed time: Typical wake time: Trouble falling asleep? Yes No Trouble staying asleep? Yes No Trouble waking up early? Yes No Any other sleep problems? Explain: Describe your diet: Describe your current level and type(s) of exercise: Mental Health History List any previous or current mental health diagnoses: Have you received therapy services or counseling in the past? Yes No Name of provider: Dates: Name of provider: Dates: Name of provider: Dates: Are you currently under seeing a psychiatric clinician (Psychiatrist, Nurse Practitioner, Physician Assistant) for medication? Yes No Have you in the active care past? Yes No Name of Clinician: Dates of treatment: Medication(s) Prescribed: Is there a physician history of self-harm or do suicidal thoughts, threats, or attempts? Please explain: Have you ever been hospitalized for mental health concerns? Please explain: Do you have any present health issuesa history of angry outbursts? ☐ YES ☐ NO Yes No If yes, please explain: Do Have you need to preever physically assaulted another person, animal, or object? Yes No If yes, please explain: Psychosocial Functioning Describe your personality: What are your non-medicate with antibiotics for any heart or other conditions before dental treatmentacademic strengths? ☐ YES ☐ NO Are What are your non-academic weaknesses? How do you taking any prescription or over the counter medications (including ibuprofen, Diet supplements, etc.)spend your free time? ☐ YES ☐ NO Please list each one: Are you pregnant or nursing? ☐ YES ☐ NO / Do you smoke? ☐ YES ☐ NO If so, how much daily? Are you allergic to (Please check all that apply): ☐ ASPIRIN ☐ CODEINE ☐ DENTAL ANESTHETICS ☐ ERYTHROMYCIN ☐ SULFITES ☐ LATEX ☐ PENICILLIN ☐ TETRACYCLINE ☐ ANY METALS ☐ OTHER: Do you drink alcohol? ☐YES ☐ NO , If so, how much daily? Please check all that apply: ☐ ARTHRITIS ☐ ARTIFICIAL BONES/ JOINTS/ VALVES ☐ ASTHMA ☐ BLODD TRANSFUSION ☐ CONGENITAL HEART DEFECT ☐ HIV/AIDS ☐ CANCER/CHEMOTHERAPY ☐ ULCERS ☐ HPV ☐ DIABETES ☐ EMPHYSEMA ☐ KIDNEY PROBLEMS ☐ FAINTING ☐ FREQUENT HEADACHES ☐ LIVER DISEASE ☐ HEART ATTACK ☐ HEART MURMUR ☐ LOW BLOOD PRESSURE ☐ HEART SURGERY ☐ HEPATITIS TYPE ☐ LUPUS ☐ HERPES/FEVER BLISTERS ☐ HIGH BLOOD PRESSURE ☐ MITRAL VALVE PROLAPSE ☐ PACEMAKER ☐ RADIATION TREATMENT ☐ RHEUMATIC/SCARLET FEVER ☐ SEIZURES ☐ SHINGLES ☐ SICKLE CELL DISEASE ☐ THYROID ☐ TUBERCOLOSIS Please list any significant medical condition(s) or surgeries you have had (not listed above): The information I have provided on this form What is accurate and complete to the best your current level of my knowledge, information and belief. I will notify the practice at the soonest practical moment of any changes in the information I have provided. In consideration of being accepted as a patient of the practice, I agree to abide by the terms and conditions of this patient application & practice management. SIGNATURE: DATE:alcohol and/or drug use?

Medical History. Are you currently under the active care of a physician or do you have any present health issuesYes No Has your child’s medical history been normal/unremarkable? ☐ YES ☐ NO If yesno, please explain: Do you need to pre-medicate with antibiotics for Yes No Has your child received any heart or other conditions before dental treatment? ☐ YES ☐ NO Are you taking any prescription or over the counter medications (including ibuprofen, Diet supplements, etc.)? ☐ YES ☐ NO Please list each one: Are you pregnant or nursing? ☐ YES ☐ NO / Do you smoke? ☐ YES ☐ NO If so, how much daily? Are you allergic to (Please check all that apply): ☐ ASPIRIN ☐ CODEINE ☐ DENTAL ANESTHETICS ☐ ERYTHROMYCIN ☐ SULFITES ☐ LATEX ☐ PENICILLIN ☐ TETRACYCLINE ☐ ANY METALS ☐ OTHER: Do you drink alcohol? ☐YES ☐ NO , If so, how much dailymedical diagnoses? Please check all that applyspecify: ☐ ARTHRITIS ☐ ARTIFICIAL BONES/ JOINTS/ VALVES ☐ ASTHMA ☐ BLODD TRANSFUSION ☐ CONGENITAL HEART DEFECT ☐ HIVYes No Has your child had genetic testing? Yes No Has your child had an MRI? Yes No Has your child had an EEG? Yes No Frequent ear infections? Yes No Were ear tubes ever placed? Yes No Hearing problems? Yes No Vision problems? Yes No Headaches? Yes No Meningitis? Yes No Seizures? Yes No Asthma? Yes No Slow/AIDS ☐ CANCERfast growth? Yes No Head injury? Yes No Allergies? Yes No Hospitalizations? Describe below. Yes No Physical/CHEMOTHERAPY ☐ ULCERS ☐ HPV ☐ DIABETES ☐ EMPHYSEMA ☐ KIDNEY PROBLEMS ☐ FAINTING ☐ FREQUENT HEADACHES ☐ LIVER DISEASE ☐ HEART ATTACK ☐ HEART MURMUR ☐ LOW BLOOD PRESSURE ☐ HEART SURGERY ☐ HEPATITIS TYPE ☐ LUPUS ☐ HERPES/FEVER BLISTERS ☐ HIGH BLOOD PRESSURE ☐ MITRAL VALVE PROLAPSE ☐ PACEMAKER ☐ RADIATION TREATMENT ☐ RHEUMATIC/SCARLET FEVER ☐ SEIZURES ☐ SHINGLES ☐ SICKLE CELL DISEASE ☐ THYROID ☐ TUBERCOLOSIS Please list Sexual Abuse? If yes to any significant medical condition(s) or surgeries you have had (not listed above): The information I have provided on this form is accurate and complete to the best of my knowledge, information and belief. I will notify the practice at the soonest practical moment of any changes in the information I have provided. In consideration of being accepted as a patient of the practiceabove, I agree to abide by the terms please describe: Has your child ever been hospitalized, had surgeries, or major illnesses? Age How long Reason What medications does your child currently take? (Include over-the-counter supplements) Name Dose Frequency Reason Describe your child’s sleep routine: Typical bed time: Typical wake time: Trouble falling asleep? Yes No Trouble staying asleep? Yes No Trouble waking up early? Yes No Any other sleep problems? Explain: Describe your child’s diet: Describe your child’s current level and conditions type(s) of this patient application & practice management. SIGNATURE: DATEexercise:

Medical History. Has your medical history been normal/unremarkable? Yes No If no, please explain: Have you received any medical diagnoses? Yes No Please explain: Circle All that Apply: Yes No Have you completed genetic testing? Yes No Have you had an MRI? Yes No Have you had an EEG? Yes No Frequent ear infections? Yes No Were ear tubes ever placed? Yes No Hearing problems? Yes No Vision problems? Yes No Headaches? Yes No Meningitis? Yes No Seizures? Yes No Asthma? Yes No Slow/fast growth? Yes No Head injury? Yes No Allergies? Yes No Hospitalizations? Yes No Have you experienced anything you would call traumatic (physical, verbal, or emotional abuse; unwanted sexual experiences; accidents or other events)? Have you ever been hospitalized, had surgeries, or major illnesses? Age How long Reason What medications do you currently take? (Include over-the-counter supplements) Name Dose Frequency Reason Describe your sleep routine: Typical bed time: Typical wake time: Trouble falling asleep? Yes No Trouble staying asleep? Yes No Trouble waking up early? Yes No Any other sleep problems? Explain: Describe your diet: Describe your current level and type(s) of exercise: Mental Health History List any previous or current mental health diagnoses: Have you received therapy services or counseling in the past? Yes No Name of provider: Dates: Name of provider: Dates: Name of provider: Dates: Are you currently under seeing a psychiatric clinician (Psychiatrist, Nurse Practitioner, Physician Assistant) for medication? Yes No Have you in the active care past? Yes No Name of Clinician: Dates of treatment: Medication(s) Prescribed: Is there a physician history of self-harm or do suicidal thoughts, threats, or attempts? Please explain: Have you ever been hospitalized for mental health concerns? Please explain: Do you have any present health issuesa history of angry outbursts? ☐ YES ☐ NO Yes No If yes, please explain: Do Have you need to preever physically assaulted another person, animal, or object? Yes No If yes, please explain: Psychosocial Functioning Describe your personality: What are your non-medicate with antibiotics for any heart or other conditions before dental treatmentacademic strengths? ☐ YES ☐ NO Are What are your non-academic weaknesses? How do you taking any prescription or over the counter medications (including ibuprofen, Diet supplements, etc.)spend your free time? ☐ YES ☐ NO Please list each one: Are you pregnant or nursing? ☐ YES ☐ NO / Do you smoke? ☐ YES ☐ NO If so, how much daily? Are you allergic to (Please check all that apply): ☐ ASPIRIN ☐ CODEINE ☐ DENTAL ANESTHETICS ☐ ERYTHROMYCIN ☐ SULFITES ☐ LATEX ☐ PENICILLIN ☐ TETRACYCLINE ☐ ANY METALS ☐ OTHER: Do you drink alcohol? ☐YES ☐ NO , If so, how much daily? Please check all that apply: ☐ ARTHRITIS ☐ ARTIFICIAL BONES/ JOINTS/ VALVES ☐ ASTHMA ☐ BLODD TRANSFUSION ☐ CONGENITAL HEART DEFECT ☐ HIV/AIDS ☐ CANCER/CHEMOTHERAPY ☐ ULCERS ☐ HPV ☐ DIABETES ☐ EMPHYSEMA ☐ KIDNEY PROBLEMS ☐ FAINTING ☐ FREQUENT HEADACHES ☐ LIVER DISEASE ☐ HEART ATTACK ☐ HEART MURMUR ☐ LOW BLOOD PRESSURE ☐ HEART SURGERY ☐ HEPATITIS TYPE ☐ LUPUS ☐ HERPES/FEVER BLISTERS ☐ HIGH BLOOD PRESSURE ☐ MITRAL VALVE PROLAPSE ☐ PACEMAKER ☐ RADIATION TREATMENT ☐ RHEUMATIC/SCARLET FEVER ☐ SEIZURES ☐ SHINGLES ☐ SICKLE CELL DISEASE ☐ THYROID ☐ TUBERCOLOSIS Please list any significant medical condition(s) or surgeries you have had (not listed above): The information I have provided on this form What is accurate and complete to the best your current level of my knowledge, information and belief. I will notify the practice at the soonest practical moment of any changes in the information I have provided. In consideration of being accepted as a patient of the practice, I agree to abide by the terms and conditions of this patient application & practice management. SIGNATURE: DATE:alcohol and/or drug use?