Form of Contact
Are you currently under another physician care?
Do you have or had? Please CHECK any that may apply of the following:
Have you ever had previous surgeries?
Please list all known allergies (1 per line):
Do you take: (Please CHECK any that may apply to the following)
List any other medications you are currently taking (1 per line):
Do you usually drink 2 or more alcoholic beverages daily?
Do you drink more then 6 cups of coffee/caffeinated drinks daily?
Have you ever received treatment for alcohol or drug abuse?
Do you often get depressed or feel unhappy?
Did you ever have a nervous breakdown?
Are you easily able to get upset or irritated?
Do you tend to hold a "Grudge" when someone angers you?
Have you ever considered consulting a psychiatrist or psychologist?
FOR WOMEN ONLY
Have you ever been pregnant?
How did you hear about us?