Your Name:

1. Have you been under a doctor's care during the past year?   Yes No If yes, please explain  

2. Have you ever been hospitalized?   Yes No If yes, please explain  

3. Have you ever had any operations?   Yes No If yes, please explain  

4. Have you ever had any of the following?  (Please check Y or N for each one)

5. Have you had any disease, drug or transplant operation that has depressed your immune system?   Yes No If yes, please explain  

6. Are you taking Bisphosphonates (Fosamax, Boniva, Actonel, Aredia, Zometa, Reclast, Prolia) for osteoporosis, chemotherapy or multiple myeloma, etc.?   Yes No

7. Do you have any past history of chemical or alcoholic dependency that may affect the care we provide?   Yes No

8. Are you taking any of the following?

9. Please list any and all medications you are currently taking, including prescription medications, over-the-counter medications, herbal or holistic remedies, vitamins or minerals

10. Are you allergic or have you had an adverse reaction to:

11. For Women Only: Are you pregnant/any chance you might be pregnant?   Yes No
Are you nursing?   Yes No
**If you are using Oral Contraceptives, it is important that you understand that antibiotics (and some other medications) may interfere with the effectiveness of oral contraceptives. Please consult with your physician.

12. Do you wish to speak with the doctor privately about anything?   Yes No