Your Name:
1. Have you been under a doctor's care during the past year?
If yes, please explain
2. Have you ever been hospitalized?
If yes, please explain
3. Have you ever had any operations?
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?
If yes, please explain
6. Are you taking Bisphosphonates (Fosamax, Boniva, Actonel, Aredia, Zometa, Reclast, Prolia) for osteoporosis, chemotherapy or multiple myeloma, etc.?
7. Do you have any past history of chemical or alcoholic dependency that may affect the care we provide?
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?
Are you nursing?
**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?