Medication History Form Name First Last OSTEOPOROSISOsteoporosis:Please check any of the following medications you currently take or have taken. Fosamax Boniva Relcast Actonel Prolia Forteo Tymlos Evista Other OtherReason for DiscontinuationRA / INFLAMMATORY ARTHRITISNon Biologic DMARDS:Please check any of the following medications you currently take or have taken. Methotrexate Plaquenil Arava Sulfasalazine Xeljanz Other Biologic DMARDS::Please check any of the following medications you currently take or have taken. Humira Enbrel Remicade Simponi Cimzia Actemra Kevzara Rituxan Orencia Other OtherReason for DiscontinuationLUPUSLupus:Please check any of the following medications you currently take or have taken. Plaquenil Azathioprine Cellcept Benlysta Cytoxan Other OtherReason for DiscontinuationPSORIASIS / PSORIATIC ARTHRITISPsoriasis / Psoriatic Arthritis:Please check any of the following medications you currently take or have taken. Stelara Taltz Cosentyx Tremfya Other OtherReason for DiscontinuationFIBROMYALGIAFibromyalgia:Please check any of the following medications you currently take or have taken. Cymbalta Neurontin Lyrica Savella Amitriptyline Nortiptyline Other OtherReason for DiscontinuationOther MedicationsHave you ever been treated with prednisone?YesNoIf yes, for how long?Was it helpful?YesNoWhat other pain medications such as NSAIDS (ibuprofen, naproxen, meloxicam), Celebrex, Opiates (tramadol, oxycodone, hydrocodone, Butrans) have you been treated with? What was your response to these other pain medications ?Important DatesPlease note the date of your most recent:PCP Visit: Date Format: MM slash DD slash YYYY Eye Exam: Date Format: MM slash DD slash YYYY DEXA Scan: Date Format: MM slash DD slash YYYY Flu Vaccine: Date Format: MM slash DD slash YYYY Pneumo Vaccine: Date Format: MM slash DD slash YYYY TB Test: Date Format: MM slash DD slash YYYY