General Medical Questionnaire

FIRST NAME: Sophia LAST NAME: Davis
MARITAL STATUS: Single Married Divorced Separated Widowed
ADDRESS: 5102 Robin Park
CITY: Heflin STATE: LA ZIP: 71039
PHONE: 584 924-3056 DOB: March 24, 1995
SPOUSE NAME: SPOUSE PHONE:

Is the requested medication NEW or a CONTINUATION of THERAPY? If so, start date: __________

Have you been hospitalized in the past year? Yes No

Previous Health History

PRIMARY CARE PHYSICIAN: Dr. Jessica Johnson LAST SEEN DATE: July 27, 1966

Have you received chiropractic care? Yes No

Have you received acupuncture care? Yes No

PRESCRIPTION DRUGS:

Antidepressants	Anti Inflammatory
Birth Control Pills	Blood Pressure Medication
Diet Pills	Blood Sugar Medication
Muscle Relaxers	Insulin
Pain Pills	Sleeping Pills

Other: omeprazole, metoprolol

OVER-THE-COUNTER DRUGS: benadryl

ACCIDENTS OR INJURIES: burn injury

VITAMINS OR SUPPLEMENTS: vitamin d, vitamin b5, msm

Review of Symptoms

Allergies	Black Outs
Blurred Vision	Calf Pain
Chest Pain	Chills
Coughing	Coughing Up Blood
Dental Problems	Difficulty Emptying Bowel Or Bladder
Double Vision	Enlarged Glands
Excessive Bruising	Excessive Stress
Excessive Thirst	Eye Pain
Fatigue	Fever
Headaches	Hearing Loss
Irregular Heart Rate	Joint Swelling
Muscle Pain	Seizures
Shortness Of Breath	Stomach Trouble Or Ulcers
Tuberculosis Exposure	Weight Gain Or Loss Greater Than 10 Lbs