REVIEW OF SYMPTOMS (history or current problem with any of the following? Please all that apply) Problems with bleeding? Yes No Wheezing Yes No □ □ □ □ Problems with healing? Yes No Red Eye Yes No □ □ □ □ Problems with scarring? □ Yes □ No Tearing □ Yes □ No Eye Pain Yes No □ □ Abdominal Pain Yes No Uncontrolled Blood Pressure Yes No □ □ □ □ Anxiety Yes No Elevated Blood Sugar Yes No □ □ □ □ Bloody Stool Yes No Allergy to adhesives Yes No □ □ □ □ Bloody Urine Yes No Allergy to Lidocaine Yes No □ □ □ □ Blurry Vision Yes No Allergy to topical antibiotic ointment Yes No □ □ □ □ Chest Pain Yes No Artificial Heart Valves Yes No □ □ □ □ Cough Yes No Artificial joints in the last 2 years Yes No □ □ □ □ Depression Yes No Blood thinners Yes No □ □ □ □ Dizziness Yes No Defibrillator Yes No □ □ □ □ Fever/Chills Yes No MRSA Yes No □ □ □ □ Grey discoloration of skin Yes No Pacemaker Yes No □ □ □ □ Hay Fever Yes No Currently pregnant □ □ Headaches □ Yes □ No or planning pregnancy □ Yes □ No Immunosuppression Yes No Premedication prior to procedure Yes No □ □ □ □ Joint Aches Yes No Rapid heartbeat w/epinephrine Yes No □ □ □ □ If yes, what year ______ Muscle Weakness Yes No □ □ Neck Stiffness Yes No Latex Allergy: Yes No □ □ □ □ Night Sweats Yes No □ □ Rashes/Hives Yes No □ □ Seizures Yes No □ □ Shortness of Breath Yes No □ □ Sleeplessness Yes No □ □ Sore Throat Yes No □ □ Thyroid Problems Yes No □ □ Unintentional Weight Loss Yes No □ □ ___________________________________________ __________________ Signature of Responsible Party Date
REVIEW OF SYMPTOMS (history or current problem with any of the following? Please all that apply) Problems with bleeding? □ Yes □ No Wheezing □ Yes □ No Problems with healing? □ Yes □ No Red Eye □ Yes □ No Problems with scarring? □ Yes □ No Tearing □ Yes □ No Eye Pain □ Yes □ No Abdominal Pain □ Yes □ No Uncontrolled Blood Pressure □ Yes □ No Anxiety □ Yes □ No Elevated Blood Sugar □ Yes □ No Bloody Stool □ Yes □ No Allergy to adhesives □ Yes □ No Bloody Urine □ Yes □ No Allergy to Lidocaine □ Yes □ No Blurry Vision □ Yes □ No Allergy to topical antibiotic ointment □ Yes □ No Chest Pain □ Yes □ No Artificial Heart Valves □ Yes □ No Cough □ Yes □ No Artificial joints in the last 2 years □ Yes □ No Depression □ Yes □ No Blood thinners □ Yes □ No Dizziness □ Yes □ No Defibrillator □ Yes □ No Fever/Chills □ Yes □ No MRSA □ Yes □ No Grey discoloration of skin □ Yes □ No Pacemaker □ Yes □ No Hay Fever □ Yes □ No Currently pregnant Headaches □ Yes □ No or planning pregnancy □ Yes □ No Immunosuppression □ Yes □ No Premedication prior to procedure □ Yes □ No Joint Aches □ Yes □ No Rapid heartbeat w/epinephrine □ Yes □ No If yes, what year ______ Muscle Weakness □ Yes □ No Neck Stiffness □ Yes □ No Latex Allergy: □ Yes □ No Night Sweats □ Yes □ No Rashes/Hives □ Yes □ No Seizures □ Yes □ No Shortness of Breath □ Yes □ No Sleeplessness □ Yes □ No Sore Throat □ Yes □ No Thyroid Problems □ Yes □ No Unintentional Weight Loss □ Yes □ No ___________________________________________ __________________ Signature of Responsible Party Date
EMA%20Patient%20Medical%20History%20Sheet.docx