Medical History Medical History, Please answer to the best of your ability, and check yes to all that apply. * Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 12345678910111213141516171819202122232425262728293031 Blackouts * Yes No Memory Problems Yes No Hallucinations * Yes No Overdose * Yes No Nausea/Vomiting * Yes No Seizures Yes No Narcolepsy * Yes No Hepatitis C * Yes No HIV Positive * Yes No High Blood Pressure * Yes No Low Blood Pressure * Yes No Heart Problems * Yes No Female Problems ( PMS, Dysmenorrhea, etc.) * Yes No Pregnant Yes No Diabetes * Yes No Cancer, Tumors, Cysts * Yes No Epilepsy/Seizures * Yes No Allergies * Yes No If your allergy can cause a life or death situation, List and Explain. * Please list all medications that you are currently taking and the durantion. * |Welcome| |Our Mission| |Our Services| |The TC| |For Women| |Children Services| |Exec. Director| |Health Center| |Job Training| |Outpatients| |FAQ| |Admissions| |Adm. Personal History| |Adm/Med/history| |Adm./Psycho/History| |Directions| |Odyssey Links| |Contact Us| |About| Hosted by AbleTeam.com