Health Questionnaire Form

List all of your current health problems

List any other doctors seen and
list treatment recieved and results obtained

List all surgeries you have had w/dates

List any MEDICATIONS you are now taking

Have you ever been in an automobile accident and when

Have you ever been in an industrial injury or any other injury for which you recieved treatment and when

Please check the conditions you have or have had

Family health problems or cause of death

[_] AIDS
[_] anemia
[_] arthritis
[_] cancer
[_] epilepsy
[_] polio

[_] multiple sclerosis
[_] Parkinson's disease
[_] rheumatic fever
[_] tuberculosis
[_] venereal disease
[_] hypoglycemia

mother
mother's mother
mother's father
father
father's mother
father's father
siblings

The Healing Experience 5150 Roswell Rd. Atlanta, GA 30342
Phone: (404) 255-3110 Fax: (404) 497-9796 gtgunter@bellsouth.net