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GENERAL HEALTH HISTORY FORM
oceancitydentists
2020-12-20T12:10:44-05:00
Health History
General Health History
Physician's Name
Date of last visit
Have you ever used a bisphosphonate medication? Common brand names are Fosamax, Actonel, Atelvia, Didronel, Boniva.
Yes
No
Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine).
Yes
No
AIDS/HIV
Yes
No
Do you wear contact lenses?
Yes
No
Psychiatric Care
Yes
No
Anemia
Yes
No
Epilepsy
Yes
