Application For Neuropathy Treatment Form Page 3
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3Previous Health History
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.
Copies of this record can only be released by your written authorization, unless you sign here indicating that
we can release copies by your verbal request:
Name:___________________________________ Signature:____________________________________Date:_______
Please give name, address, and office phone of your primary care physician/family doctor?:
Name: _________________________________________________
When were you last seen there:_______________________________
May we send them updates on your treatment/condition: □Yes □No
List ALL Allergies (or Sensitivities) to Medicines, Foods, and other items:
Item you react to:
Reaction:
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Please list the prescription drugs you are currently taking, or attach list:
Name:
Dose (MG or IU)
Times Daily
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List all Nutritional Supplements (vitamins, herbs, homeopathics, etc.) as above:
_________________________________
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Date of Above List: _____________________________________________
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