Supplements Intake Form

Step 1 of 2

Patient's Name

Today's Date

1) Health concern #1:

How long has this problem been bothering you?

How often does it bother you?

How severe (1-10) is the intensity of this problem?

Better with anything? Worse with anything?

Other relevant info?

Add 2nd Health Concern

Yes

2) Health concern #2:

How long has this problem been bothering you?

How often does it bother you?

How severe (1-10) is the intensity of this problem?

Better with anything? Worse with anything?

Other relevant info?

Add 3rd Health Concern

Yes

3) Health concern #3:

How long has this problem been bothering you?

How often does it bother you?

How severe (1-10) is the intensity of this problem?

Better with anything? Worse with anything?

Other relevant info?

NOTE: If you have OTHER health concerns you would like to discuss with Dr. Sharif, list them all on a second page. Typed-up would be much preferred to hand-written.

Do you have other health concerns you'd like to discuss?

Yes

List

Health Concern

Notes to Dr. Sharif

Supplements Intake Form

1) Health concern #1:

2) Health concern #2:

2) Health concern #2:

3) Health concern #3:

PLEASE PROVIDE A LIST OF ALL OF YOUR DRUGS & SUPPLEMENTS: