| Page: | Name: ___________________________________________ |
| Concerns and Historical Facts: | |
| Dates: | Abbreviations: Sx=Surgery Hx=History F=Familial C=Current R=Resolved /d =per day |
| SE= Side Effects /wk = per week d/d= drops/day DC= Discontinue | |
| Surgeries: | |
| Cravings: | |
| Scars: | |
| Congenital defects: | |
| Dr. Denice Moffat www.NaturalHealthTechniques.com 1069 Elk Meadow Lane | |
| Deary, Idaho 83823 U.S.A. (208) 877-1222 | |
History and Concerns Form
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