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

Dr. Denice Moffat, Naturopath & Medical Intuitive
Telephone Consultation Services
(208) 877-1222  (Pacific Time)
(208) 877-1969 Consult line

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1069 Elk Meadow Lane
Deary, ID 83823 U.S.A