Patient Medical History

Are you under a physician's care now?

yes

no

If yes

Have you ever been hospitalized or had a major operation?

yes

no

If yes

Have you ever had a serious head or neck injury?

yes

no

If yes

Are you taking any medications, pills, or drugs?

yes

no

If yes

Do you take, or have you taken, Phen-Phen or Redux?

yes

no

If yes

Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?

yes

no

If yes

Are you on a special diet?

yes

no

Do you use tobacco?

yes

no

Do you use controlled substances?

yes

no

If yes

Are you allergic to any of the following?

Other

yes

If yes

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