Medical History

1. Any past or current medications?
2. Any allergies?
3. Any reduced capabilities?
4. Any preceding illnesses before these symptoms began?
5. Any falls or accidents prior to these symptoms?
6. Any previous emotional upsets?
7. Any unexplained crying or tearing?
8. Any past injuries?
9. Does anyone in your family have similar symptoms?
10. Past medical history; surgeries, psychiatric, X-rays, laboratory tests.
11. Do you drink alcohol? How many drinks a day? How often? What do you drink?
12. Do you use tobacco products? What types? How often?
13. Do you use any recreational drugs?

©2000,  Neal R. Chamberlain, Ph.D.. All rights reserved.