Medical History Form Page 3
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1
2
3:
U
S
E
O
F
R
E
C
R
E
A
T
I
O
N
A
L
D
R
U
G
S
A
N
D
S
U
B
S
T
A
N
C
E
S
U
S
E
O
F
R
E
C
R
E
A
T
I
O
N
A
L
D
R
U
G
S
A
N
D
S
U
B
S
T
A
N
C
E
S
How much and how often do you use:
alcohol:
marijuana:
prescription medications (for anxiety and pain):
cigarettes:
other (list):
(AA, Recovery, Inpatient):
TREATMENT PROGRAMS
,
&
:
,
&
:
M
M
E
E
D
D
I
I
C
C
A
A
L
L
E
E
X
X
P
P
E
E
C
C
T
T
A
A
T
T
I
I
O
O
N
N
S
S
B
B
E
E
L
L
I
I
E
E
F
F
S
S
H
H
O
O
P
P
E
E
S
S
How confident are you in your current medical (allopathic and/or alternative)
provider(s) (MD, DO, NP, etc) and in your health care system (system):
If you are interested in pursuing medical interventions for your symptoms and/or
problems, what specific medications are you interested in trying and what do you
hope to achieve:
Rev. 7/07
Medical History Form
3
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