CATOOSA HOPE CLINIC
MEDICAL AND PRESCRIPTION HISTORY
NAME___________________________________________DATE OF BIRTH_______________TODAY’S DATE________________
IN ORDER TO SAFELY ASSESS THE BEST TREATMENT OPTIONS FOR OUR PATIENTS IT IS IMPERATIVE TO HAVE AN ACCURATE
MEDICAL HISTORY, INCLUDING MEDICAL DIAGNOSES, PROCEDURES, AND PRESCRIPTION MEDICATIONS. PLEASE FILL OUT THE
FOLLOWING.
MEDICAL HISTORY (Please use the back of the page if you need more room.)
DIAGNOSIS/DISORDER
DATE OF
DIAGNOSIS
IS THIS CONDITION RESOLVED, CHRONIC
BUT MANAGED WITH TREATMENT, OR
CHRONIC BUT NOT BEING TREATED
CURRENTLY?
TREATMENT PROVIDER
(IF APPLICABLE)
PRESCRIPTION HISTORY Please list all medications, including prescriptions, vitamins, supplements, herbal medications
and over-the-counter medications. Please copy information for prescribed medications from the pill bottle or prescription
label. (Please use the back of the page if you need more room)
MEDICATION NAME
DOSAGE
DIRECTIONS ON LABEL FOR
PRESCRIBING PHYSICIAN
(mg, mcg, I.U.)
TAKING MEDICATION
(IF APPLICABLE)
DO YOU HAVE ANY UNADDRESSED MEDICAL PROBLEMS? (If so please explain)________________________________________
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