Form26 - [FORM 26-Use the top of this page for your...

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FORM 26 —Use the top of this page for your letterhead.] Brief Health Information Form A. Identification Client’s name: Case #: Date: B. History 1. Starting with your childhood and proceeding up to the present, list all diseases, illnesses, important accidents and injuries, surgeries, hospitalizations, periods of loss of consciousness, convulsions/seizures, and any other medical conditions you have had. (Describe pregnancies in section E.) Age Illness/diagnosis Treatment received Treated by Result 2. Describe any allergies you have. To what? Reaction you have Allergy medications you take 3. List all medications, drugs, or other substances you take or have taken in the last year—prescribed, over-the- counter vitamins, supplements, herbs, and others. Medication/drug Dose (how much?) Taken for Prescribed and supervised by (cont.) FORM 26. Brief health information form (p. 1 of 3). From The Paper Office . Copyright 2008 by Edward L. Zuckerman. Permission to photocopy this form is granted to purchasers of this book for personal use only (see copyright page for details).
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This note was uploaded on 07/01/2010 for the course COUN 6682 A and taught by Professor All during the Spring '10 term at Walden University.

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Form26 - [FORM 26-Use the top of this page for your...

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