PATIENT HISTORY

Name__________________________________________ Date____________________

Allergies________________________________ Age_____ Birth Control____________

Referred By _______________________________________________

Other Doctor(s) Patient Sees:

Dr. Name ________________________________ Specialty ______________________

Dr. Name ________________________________ Specialty ______________________

Dr. Name ________________________________ Specialty ______________________

Reason(s) For Your Visit:

1. __________________________________________________________________

2. __________________________________________________________________

3. __________________________________________________________________

Tell Us More About Your Reason(s) (Symptoms) For Your Visit:

1. __________________________________________________________________

2. __________________________________________________________________

3. __________________________________________________________________

Prescriptions Your Are Presently Taking:

MEDICATION NAME DOSE & FREQUENCY TAKEN PRESCRIBING DOCTOR

1.___________________ ____________________________ ______________________

2.___________________ ____________________________ ______________________

3.___________________ ____________________________ ______________________

4.___________________ ____________________________ ______________________

5.___________________ ____________________________ ______________________

Vitamin, Mineral, Herbal, or Nutritional Supplement Presently Taken:

SUPPLEMENT NAME DOSE & FREQUENCY TAKEN

1.___________________ ____________________________ ______________________

2.___________________ ____________________________ ______________________

3.___________________ ____________________________ ______________________

4.___________________ ____________________________ ______________________

5.___________________ ____________________________ ______________________