HEALTH INFORMATION

HEALTH INFORMATION
NAME_______________________________	DATE______________________
Please list ALL medications:	Identify dose:
1 __________________________________	____________________________
2 __________________________________	____________________________
3 __________________________________	____________________________
4 __________________________________	____________________________
5 __________________________________	____________________________

List any vitamins you take._______________________________________
___________________________________________________________________
Do you exercise? How? ___________________________________________________________________
Do you have Premenstrual Syndrome? (PMS)_____
Please notify your counselor if there is ANY change in your medication or health.
___________________________________________________________________ . . .