(Ongoing or Long-Term Problems like high blood pressure, diabetes, etc)
(Indicate any lab tests, xrays, MRI/CT, etc. that you have had recently. Please include the date or approximate date.)
Colonoscopy?
Mammogram?
Flu vaccine?
Pneumonia vaccine?
(Includes Specialists, Chiropractors, Therapists, In-Home Care, etc.)
(New or short term problems. Example : Cough, injury, constipation, etc)
(Check all symptoms that you are feeling)