Primary health problems/symptoms:
Any past/current use of: Laxatives, Antacids, Painkillers, Sleeping Pills, Oral Contraception, Antibiotics, Vitamins/Minerals Supplements, Other?
FAMILY HISTORYMajor health problems in the family
LIFESTYLEDescribe your Home Situation, Work Situation, Hobbies/Pastimes, Recreational drugs usage
EXERCISE HABITS Describe duration, intensity, frequency
(Please check all that apply)
OTHER RELEVANT INFORMATION