MED Which Pharmacy do you use?Please list all the medications you are currently taking (include birth control pills, insuline, aspirin, and all over the counter medicines)I am allergic to (include medicines, foods, pollens, latex, etc.), and what type of reaction you had:Social HistoryWho do you live with? Parents Spouse Children Significant other Alone How many children do you haveAre you currently Employed Unemployed Disabled Occupation (current or former)How many caffeinated beverages do you drink per day? (coffee, cola, tea)Do you participate in regular exercise?Are you a competitive athleteDo you now, or have you ever smoked? How much per day and how long?If you no longer smoke, when did you quit?Do you now, or did you ever drink alcohol? How much?Do you now, or have you ever used recreational drugs?Which drugs and how much?If you no longer use drugs, when did you quit? Δ
