Please rank current and ongoing health problems by priority and fill in the other boxes as completely as possible:
Y= Yes (currently or in the past year)
***If no history of the symptom, please leave blank.***
Condition/Symptom (indicate Y or P)
Comments (for doctor’s use only)
Please list any imaging you have had done (x-rays, MRI, Bone scan, etc.)
Please list dates and reasons:
Please list ALL current prescription and non-prescriptions medications, dosage, and reasons:
Please list all allergies (foods, medications, airborne):
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