Todays Date 

Birthdate 

Do you consider yourself in good health?

Yes    No 

Are you subject to prolonged bleeding?

Yes    No 

Are you pregnant?

Yes    No 

Do you have a prosthetic hip or knee?

Yes    No 

Do you have a cardiac pacemaker?

Yes    No 

Do you have a prosthetic heart valve?

Yes    No 

Do you have a heart murmur?

Yes    No 

Have you ever taken biophosphonates (e.g., Fosamax)?

Yes    No 

Are you allergic to Latex?

Yes    No 

Can you take ibuprofen?

Yes    No 

Hepatitis

Yes    No 

Tuberculosis

Yes    No 

Kidney Trouble

Yes    No 

Liver Trouble

Yes    No 

Epilepsy

Yes    No 

G.I. Ulcers

Yes    No 

GERD

Yes     No  

AIDS/HIV

Yes     No  

High Blood Pressure

Yes     No  

Diabetes

Yes     No  

Blood Disorders

Yes     No  

Fainting Spells

Yes     No  

Radiation Therapy

Yes     No  

Chemotherapy

Yes     No  

Glaucoma

Yes     No  

Asthma

Yes     No