a Form – Health and Medical Background

[vc_row row_type=”2″ blox_padding_top=”50″ blox_bgcolor=”#ffffff”][vc_column][vc_row_inner][vc_column_inner width=”2/3″][vc_column_text]

Health and Medical Background

    Describe your current health status:
    Describe any medical conditions or disabilities you currently have:
    List any Prescription Medicines you use:
    List any ‘over the counter’ medicines you use on a regular basis:
    Have you ever been hospitalized for mental health reasons? If yes, please explain
    Please list date of last alcohol consumption:
    Please list date of last drug use and drug of choice:

    [/vc_column_text][/vc_column_inner][vc_column_inner width=”1/3″][vc_wp_custommenu nav_menu=”37″ title=”Customer Forms”][/vc_column_inner][/vc_row_inner][/vc_column][/vc_row]