Please list the names, doses and frequency of all medications (including over-the-counter medications) you're currently taking.
Please describe all known allergies, as well as the adverse reactions they cause.
Please describe your current & past medical problems.
Please list the dates and descriptions of all past surgeries.
Please describe any emergency room admissions in the past 3 months.
HISTORY OF SUBSTANCE ABUSE
For each substance listed, please describe how much you use, how often you use it, when you used it last and for how many years you have been using it.