Name Date (approx.) Testing/Treatment
Condition Date of onset (approx.) Practitioner
List all medications you are currently using, or have used recently. Include over the counter medications. List dosages and approximate length of time you have used each medication:
List (include name, brand, dosage) all vitamins, minerals, herbs, and other natural products you are currently using:
List medication/supplement/environmental allergies or intolerances and associated reactions:
Please include dates.
(illness, stress, medication, smoking, alcohol, traumatic deliver)
(i.e. allergies, diet, dislike)
