Medical History

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Patient Name:

Question

Is the patient currently being treated for any symptom or condition?
Is the patient currently taking blood thinners?
Has the patient taken Fosamax, Boniva, Actonel or other Bisphosphonates?
Is the patient experiencing unusual weight loss or malnutrition?
Allergies and Medical Symptoms and Conditions (Please check all that apply)
Patient is Allergic To:
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