Physician's Name*
Date of last visit*
Have you ever taken Fosamax, Actonel, Boniva, Zometa, Aredia, or any other biophosphonate? YesNo
Are you pregnant? YesNo
Are you nursing? YesNo
Are you using any type of birth control? YesNo
Have you had a serious illness or injury? YesNo
if yes, describe?
Have you ever had a blood transfusion? YesNo
if yes, approx. dates?
Are you allergic to or have reacted adversely to any of the following medications? YesNoAspirinLocal AnestheticErythromycinPenicillinCodeineLatex
Anemia YesNo
Food Allergies YesNo
Radiation Treatment YesNo
Arthritis, Rheumatism YesNo
Glaucoma YesNo
Respiratory Disease YesNo
Artificial Heart Valves YesNo
Headaches YesNo
Rheumatic/Scarlet Fever YesNo
Artificial Joints YesNo
Heart Murmur YesNo
Rapid Weight Gain/Loss YesNo
Asthma YesNo
Heart Problems YesNo
Shingles YesNo
Back Problems YesNo
Hemophilia YesNo
Shortness of Breath YesNo
Bleeding Abnormaly YesNo
Hepatitis YesNo
Skin Rash YesNo
Blood Disease YesNo
Hernia Repair YesNo
Sleep Apnea YesNo
Cancer YesNo
High Blood Pressure YesNo
Spinal Bifida YesNo
Chemical Dependency YesNo
High Cholesterol YesNo
Stroke YesNo
Chemotherapy YesNo
HIV/AIDS YesNo
Surgical Implant YesNo
Circulatory Problems YesNo
Jaw Pain YesNo
Swelling of Feet or Ankle YesNo
Cortisone Treatments YesNo
Kidney Disease YesNo
Thyroid Problems YesNo
Cough, Persistent YesNo
Liver Disease YesNo
Tobacco Habit YesNo
Cough up Blood YesNo
Mitral Valve Prolapse YesNo
Tonsilitis YesNo
Diabetes YesNo
Nervous Problems YesNo
Tuberculosis YesNo
Epilepsy YesNo
Pacemaker YesNo
Ulcer YesNo
Fainting YesNo
Psychiatric Care YesNo
Venereal Disease YesNo
List medications you are currently taking and correlating diagnosis*
Allergies to any other medications*
