Please list as many as you can in order of importance*
Please type NONE if you do not currently take any medications.
You took these medications for a long period of time but no longer do.
Type of Illness/Operation | Date | Location
General Pain Symptoms
It is very important that you answer ALL that apply to you.*
Skin and Hair
Weight, skin, hair, teeth, stomach, sleep, depression, etc.
These are health problems that you struggled with but no longer do.
Improvements or lack of improvement in treating your health problems, sleep, vitality, mental and emotional state, etc.