Please list ANY/ALL you are CURRENTLY taking. Please include the dosage and for what condition. Please also include the length of time you have been taking it.
ie. chicken pox, mumps, etc.
Please immunizations received with date(s), if known.
ie. diabetes, strokes, hepatitis, etc.
Please list all major surgeries/injuries and the date(s).
If you have been pregnant in the past, please describe the following:
Please provide date of last menses.
Please list all drug and non-drug allergies. Please include type of reaction.
Please list any major conditions in your family including mother (her parents), father (his parents) and siblings:
Do you drink alcohol? If so, what do you drink and how often? Please include daily, weekly, monthly, etc.
Do you smoke cigarettes? If so, how many packs per day and for how many years have you been smoking?
Please list any other substances you use and how much/often. Also include your method of use.
Please describe the typical meals you eat for breakfast/lunch/dinner/snacks including beverages and amounts consumed.