List the name, area of specialty, and address of all healthcare providers that are currently taking care of you. This should include, but is not limited to, primary care Physician, ENT, Neurologist, Rheumatologist, Dentist, Chiropractor, Physical Therapist, Acupuncturist, Nutritionist, Psychiatrist, Psychologist, Massage Therapist, etc.
Prescription medications: List all prescription medications, dosage, when in the day you take it, and who prescribed it: (attach additional sheet if more space is needed)
List all health care providers that you have seen for your present condition. Include their area of specialty, treatment provided, effectiveness of treatment, and date of treatment: (effectiveness scale 0-3 where 0=not effective and 3=very effective)