Medical History:
Please read the
following very carefully. If you have any of the
following medical conditions, please follow with
an accurate explanation.
D o
you or any of your immediate family have a
history of the following medical conditions?
Blood disorders e.g. anemia,
hemophilia, hemochromatosis, phlebitis,
sickle cell anemia, thalassemia, thrombosis,
hypercholesterolemia, etc.
Cancer e.g. brain, breast, bladder,
colorectal, endometrial, leukemia, lung,
lymphoma, multiple myeloma, ovarian,
prostate, skin, testicular, etc.
Cardiovascular disease e.g. angina,
arrhythmia, atrial fibrillation,
claudication, congestive heart failure,
valve disorder, heart attacks, high blood
pressure, strokes, etc.
Endocrine disorder e.g. diabetes,
goiter, hyperthyroidism, hypothyroidism,
pheochromocytoma, thyroiditis, etc.
Eye disorders e.g. cataracts,
glaucoma, retinal complications, etc.
Gastrointestinal disorder e.g. acid
reflux, hiatal hernia, irritable bowel
syndrome (Crohn's disease, ulcerative
colitis), polyps, rectal bleeding, ulcers,
etc.
Genitourinary disorder e.g. benign
prostatic hyperplasia, cysts, endometriosis,
pelvic inflammatory disease, etc.
Immune disorders e.g. Hashimoto's
disease, eczema, HIV, Graves disease,
Sjogrens syndrome, sarcoidosis, sclerodoma,
etc.
Kidney (urinary tract) disorder e.g.
bladder disorders, cystic disease,
glomerular disease, nephrotic syndrome,
renal failure, urinary tract complications,
etc.
Liver disorder e.g. cirrhosis, Gilbert's
syndrome, hepatitis, hemochromatosis, Wilson's
disease, etc.
Musculoskeletal e.g. arthritis,
back/spine complications, fibromyalgia, gout,
lyme disease, muscular dystrophy, myasthenia
gravis, osteomalacia, osteoporosis, rickets,
spinal cord injury, etc.
Neurological disorder e.g. Alzheimer's
disease, epilepsy, head injuries, headaches,
Huntington's disease, multiple sclerosis,
seizure, etc.
Psychological disorder e.g. anxiety,
attention deficit disorder, bipolar disorder,
depression, obsessive compulsive disorder, panic
disorder, post traumatic stress disorder, etc.
Respiratory disorder e.g. allergic
rhinitis, asthma, chronic bronchitis, emphysema,
tuberculosis etc.
Other e.g. acne, chemical dependency,
menopause, nutritional disorder, obesity,
pregnant/nursing, significant trauma, etc.
Do you
have a history of any of the medical conditions
previously mentioned including Blood disorders ,
Cancer , Cardiovascular disease,
Endocrine disorder , Eye disorders , Gastrointestinal disorder ,
Genitourinary
disorder Immune disorders, Kidney
(urinary tract) disorder , Liver disorder
Musculoskeletal , Neurological disorder ,
Psychological disorder , Respiratory
disorder , Other conditions (not
mentioned)?
If yes, please
explain. For example, duration of illness, any surgery or treatment
(ten year history of hypertension (high blood
pressure), Atenolol 50mg one per day - well
controlled with medications, Blood pressure
132/84):
Yes
No
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Tramadol Specific Questions: Please read the following list of medical
questions carefully. Be sure to give any
explanations if your answer is "yes" to any of
the following.
Have you ever
had an allergic reaction to Tramadol? If yes please explain.
Yes
No
Have you ever had a seizure, head injury,
kidney and/or liver disease, alcohol and/or
drug abuse? If yes please explain.
Yes
No
Do you, or
have you taken antidepressants? If yes please explain.
Yes
No
Do you take a
Monoamine Oxidase inhibitor type medication? If yes please explain.
Yes
No
Do you have a
history of narcotic or opiate usage or are
you taking any of the following medications?
Carbamazepine (e.g., Tegretol),
anti-depressants (e.g., SSRI-types such as
fluoxetine or fluvoxamine); monoamine
oxidase (MAO) inhibitors (furazolidone
[e.g., Furoxone], isocarboxazid [e.g.,
Marplan], phenelzine [e.g., Nardil],
procarbazine [e.g., Matulane], selegiline
[e.g., Eldepryl], tranylcypromine [e.g.,
Parnate]), carbamazepine; narcotic pain
relievers (e.g., codeine), drugs used to aid
sleep; antidepressants;, MAO inhibitors
(e.g., furazolidone, linezolid, phenelzine,
procarbazine, selegiline, tranylcypromine),
psychiatric medicine (e.g., nefazodone),
"triptan"-type drugs, anti-anxiety drugs
(e.g., diazepam), sibutramine; Neuroleptics;
Chlorpromazine, Triflupromazine,
Mesoridazine, Thioridazine, Acetophenazine,
Fluphenazine HCl, Perphenazine,
Prochlorperazine, Trifluoroperazine,
Chlorprothixene, Thiothixine, Haloperidol,
Loxapine, Molindone, Clozapine, Risperidone,
Olanzapine, Quetiapine; cardiovascular
medications: Digoxin, Warfarin, Coumadin.
Also, report use of certain antihistamines
(e.g., diphenhydramine) which are also
present in many cough-and-cold products. If yes please explain.
Yes
No
For what
condition(s) or medical problem(s) are you
requesting Tramadol?
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