Orange County 714-245-9910
Inland Empire 951-307-0707
Los Angeles 213-212-3500

Long Beach 562-203-3911
Bay Area 408-482-9679

a Form – Health and Medical Background

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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:

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