Medical History Form
* required field

Medical History Form

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-Fen 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?
Women: Are you...
Are you allergic to any of the following?
Do you use controlled substances?
Do you have, or have you had, any of the following?
Have you ever had any serious illness not listed?

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