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 take, Phen-Fen or Redux?
Are you on a special diet?
Do you use controlled substances?
Have you ever taken Fosamax, Boniva, Actonel, or any other medications containing bisphosphonates?
Do you use tobacco?
Do you need to pre-medicate?
Are you allergic to any of the following?
Do you have, or have you had, any of the following?
Have you ever had any serious illness not listed above?

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my(or patient's) health. It is my responsibility to inform the dental office of any changed in medical status.

Sign above