Allergies: Please list any allergies and describe the reaction that occurred
Over-the-Counter Medication History: Please list all non-prescription medications that you are taking. (Include vitamins, herbals, and supplements):
Medical Conditions/Diseases: Please list any conditions/diseases that you have been diagnosed with or suffer from.
(Examples include: Heart diseases, high blood pressure, depression, ulcers, arthritis, insomnia, etc).
Current Prescription Medications (including hormones):
Have you had any of the following tests performed?
Doctor that we should contact for this therapy:
address