Are you currently taking or have you ever taken any bisphosphonate drugs? These include: alendronate (Fosamax), clodronate (Ostac, Bonefos), etidronate (Didronel), ibandronate (Boniva), pamidronate (Aredia), risedronate (Actonel), tiludronate (Skelid), zoledronic acid (Zometa). YesNo
Do you take or have you taken Phen-Fen or Redux? YesNo
Do you smoke or chew tobacco? YesNo
Do you use alcohol, cocaine, or other drugs? YesNo
Do you wear contact lenses? YesNo
Are you on a special diet? YesNo
Have you lost or gained more than 10 pounds in the past year? YesNo
Do you use more than two pillows to sleep? YesNo
Have you ever had any excessive bleeding requiring special treatment? YesNo
Have you been treated in a hospital in the last five years? YesNo
Do you wish to talk to the dentist privately about any problems/concerns? YesNo
All of the above information is correct to the best of my knowledge. 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 changes in medical status. I understand that the above information is necessary to provide me with dental care in an efficient and safe manner. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release information to you.
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