Medical History Update Form

1

Name

First Name

Last Name

2

Have your ever taken any of the groups of drugs collectively referred to as “fen-phen?”* This field is required.These include combinations of lonimin, Apidex, Fastin,(brand names of phentermine), Pondimin (lenfluramine) and Redux(dexfenluramine).

Yes

No

4

Medical History Signature* This field is required.

Clear

5

List any medications you are currently taking and the correlating diagnosis.* This field is required.If none, please type in none.

6

Medications Signature* This field is required.

Clear

8

Allergies Signature* This field is required.

Clear

9

Dentist SignatureDr. Arash Vahid

10

Patient Signature* This field is required.