Health HistoryInterested in working together? Fill out some info and we will be in touch shortly! We can't wait to hear from you! List ALL medications and supplements you take (Prescription and over the counter). List ALL previous surgeries and dates: List all know DRUG and FOOD allergies including reactions. Check ALL medical conditions that you may have had or currently have now: ADD/ADHD Anemia Asthma Arthritis Cancer Chroni Fatigue Migraine Depression Diabetes Epilepsy/Seizure Gout Heart Disease Hepatitis High Blood Pressure HIV/AIDS Lupus Miscarriage Multiple Sclerosis Stroke Thyroid Problems Ulcers Other: Alcohol Use Yes No Frequency Tobacco Use Yes No If yes, for how many years? Thank you!
