Patient Medical History

    Patient Information
    I would like to receive correspondences via email.
    Are you under a physician's care now?
    Have you ever been hospitalized or had a major operation?
    Have you ever had a serious head or neck injury?
    Are you taking any medications, pills, or drugs?
    Do you take, or have you taken, Phen-Phen or Redux?
    Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
    Are you on a special diet?
    Do you use tobacco?
    Do you use controlled substances?
    Women, are you:
    Pregnant/Trying to get pregnant?
    Taking Oral Contraceptives?
    Are you allergic to any of the following?
    Do you have or have you had, any of the following?

    Skip to content