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?

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