List all medication you are currently taking and why
you are taking them:
Are you allergic to any of the following?
List any other allergies:
in health status (hospitalizations, serious illness)?
Please describe health status changes:
Are you pregnant or nursing?
Are you taking birth control pills?
Do you smoke?
Do you have diabetes?
Do you get headaches?
Please indicate frequency & severity:
Do you have any artificial joints?
Please indicate date placed:
Do you snore, gasp for air, or wake up fatigued?
anything specific you would like to talk to the doctor about today: