Glplawfirm.com

GILL, LADNER & PRIEST, PLLC
403 South State Street
Jackson, MS 39201-5020
FOSAMAX QUESTIONNAIRE
Referred by:_____________________________ COMPLETED BY:______________________________________________________________ Home_____________________ Work____________________ Cell_________________ IF YOU ARE MARRIED, NAME OF SPOUSE:
PRIOR NAMES YOU HAVE USED:
IF YOU HAVE CHILDREN:
NEAREST RELATIVE/FRIEND (for purpose of another contact if unable to reach you)
PRODUCT INFORMATION
Date Fosamax prescription was filled:_______________________________________________ How often did you take the drug and at what dosage?:__________________________________ Reason drug was prescribed: ______________________________________________________ ______________________________________________________________________________ Do you currently have your prescription bottles or pharmacy records? (circle one) Yes No If so, please hold on to all prescription bottles. DO NOT DESTROY.
Which pharmacy(s) have you had you prescriptions filled: Name: __________________________________________________________________ Address: ________________________________________________________________ Telephone: _______________________________________________________________ Name: __________________________________________________________________ Address: ________________________________________________________________ Telephone: ______________________________________________________________ Please describe any oral or dental surgery performed BEFORE taking Fosamax.
Name and address of doctor(s) who treated you for these problems: Please describe any oral or dental surgery performed AFTER taking Fosamax.
Name and address of doctor(s) who treated you for these problems: Since taking Fosamax have you experienced jaw pain or been told you have osteonecrosis? If you sought treatment, list the doctor and a brief description of what you were told: Please list ALL medications you have taken BEFORE taking Fosamax.
Please list ALL medications are you currently taking:
Please check if you have had any of the following symptoms BEFORE or SINCE taking Fosamax.
Please check if you have had any of the following CONDITIONS OR MEDICATIONS OR TREATMENTS BEFORE or SINCE taking Fosamax.
PAST MEDICAL HISTORY BEFORE USE OF FOSAMAX
Please give dates when you became aware of any of the following health problems, if possible: History of any illegal drug use:
History of any alcohol use:
Past medical history (include medical and surgical illness, hospitalizations, etc):
_______________________________________________________________________________ ________________________________________________________________________________ _______________________________________________________________________________ ________________________________________________________________________________ _______________________________________________________________________________ ________________________________________________________________________________

Source: http://www.glplawfirm.com/Practice-Areas/Defective-Drugs-And-Products/fosamax_questionnaire.pdf