Form Cms-R-131 - Application For Peripheral Neuropathy Treatment Page 3
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10Previous Health History
Please give name, address, and office phone of your primary care physician/family doctor:
Name:
When were you last seen? :
List ALL Allergies (or Sensitivities) to Medicines, Foods, and other items:
Item you react to:
Reaction:
Please list the prescription drugs you are currently taking, or attach list:
Name:
Dose (MG or IU)
Purpose
List all Nutritional Supplements (vitamins, herbs, homeopathic, etc.) as above:
Rate on a scale of: 5 (very willing) to 1 (not willing).
In order to improve your health, how willing are you to:
Significantly modify your diet
5 _____ 4 _____ 3 _____ 2 _____ 1 _____
Take nutritional supplements each day
5 _____ 4 _____ 3 _____ 2 _____ 1 _____
Keep a record of everything you eat each day
5 _____ 4 _____ 3 _____ 2 _____ 1 _____
Modify your lifestyle (e.g. work demands, sleep habits)
5 _____ 4 _____ 3 _____ 2 _____ 1 _____
Practice relaxation techniques
5 _____ 4 _____ 3 _____ 2 _____ 1 _____
Engage in regular exercise
5 _____ 4 _____ 3 _____ 2 _____ 1 _____
Have periodic lab tests to assess progress
5 _____ 4 _____ 3 _____ 2 _____ 1 _____
This is a confidential record of your medical history and pertinent personal information. The doctor reserves
the right to discuss this information with medical and allied health professionals per the informed consent.
By providing the signature below, I certify that the information provided is accurate and true.
Name:
Signature:
Date:
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