Medical History
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Patient Name and DOB
Are you under the care of a physician? *
Required
Have you ever been hospitalized or had major outpatient surgery? If yes, please list. *
Please list all current medications (include Vitamins, Supplements, and Birth Control) *
Have you ever taken Bisphosphonates (i.e. Fosomax, Actonel, Zomeda)?
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Do you follow a special diet? If so, please explain.
Do you use tobacco? If so, indicate what kind and how often.
Are you :
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Please list any allergies or sensitivities (i.e. medications, tree nuts, metals)
Do you currently take any controlled substances?
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Do you have a history of alcoholism or addiction?
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