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Below, please list three to five of your most important health concerns, in the order of importance to you. (For example, #1 is most important and #5 is least important). You are welcome to enter as much information as you feel is necessary.
Please write a chronological history that summarizes your medical history in regards to the above concerns. Example: I was well until January 2002 when I had the flue. Since then, I have had daily headaches, etc. Please feel free to elaborate
Please list all food, environmental and/or drug allergies
Please list all previous medical procedures, surgeries, hospitalizations & serious illnesses. Indicate the approximate date/year and the Surgery, hospitalization, procedures, serious illnesses and/or injuries
Have you taken thyroid medication in the past if so what kind, dose and frequency? Have you taken bio-identical hormone replacement in the past and if so what form and at what frequency? Please list the medications and/or supplements that you are currently taking, with dosages, including prescription medications (e.g. Prozac, atenolol, etc.), non prescription medications (e.g., asprin, Tylenol, ibuprofen) and/or health supplements (e.g., vitamins, minerals, herbs). Please indicate name of medication, dose in milligrams or grams (or number of capsules, tablets), Frequency taken and Duration you've been taking it.
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