Information for the Physician
1. All medications, vitamins and health care preparations you are using for any reason.
Medication Dosage When and How Used
______________________ _____________ _______________________________
______________________ _____________ _______________________________
______________________ _____________ _______________________________
______________________ _____________ _______________________________
______________________ _____________ _______________________________
______________________ _____________ _______________________________
2. A medical history of yourself and your family:
Your history
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Mother's side of the Family
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Father's side of the Family
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
3. Describe changes in:
appetite or diet ___________________________________________________________
________________________________________________________________________
weight __________________________________________________________________
________________________________________________________________________
sleep patterns ____________________________________________________________
________________________________________________________________________
sexual interest __________________________________________________________
________________________________________________________________________
ability to concentrate ______________________________________________________
________________________________________________________________________
memory
_________________________________________________________________
________________________________________________________________________
Have you recently had:
____ headaches (describe)
________________________________________________________________________
____ numbness or tingling anywhere (where?)
________________________________________________________________________
____ loss of balance (describe)
________________________________________________________________________
____ double vision or vision problems (describe)
________________________________________________________________________
____ periods of amnesia (describe)
________________________________________________________________________
____ coordination changes (describe)
________________________________________________________________________
____ weakness in arms or legs (describe)
________________________________________________________________________
____ fever (describe)
________________________________________________________________________
____ nausea or diarrhea (describe)
________________________________________________________________________
____ other gastrointestinal problems (describe)
________________________________________________________________________
____ fainting or dizziness (describe)
_______________________________________________________________________
____ seizures (describe)
_______________________________________________________________________
____ stressful life events (describe)
_______________________________________________________________________
Add additional sheets for other pertinent information.