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  • VITAL TOTAL HEALTH Medical Group, Inc.

    Walnut Creek - San Francisco - Oakland - Pleasanton - Folsom - Beverly Hills

    www.VitalTotalHealth.com www. VitalOncall.com

    Central Phone and Fax (925) 388-9800

  • SUBSTANCE USE QUESTIONNAIRE

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  • PAST INJURIES: Have you had any past injuries? If so, then note below.*
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  • Do you have any Pain?*
  • Date of Injury or Illness:
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  • Frequency of Pain:
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  • PAST MEDICAL HISTORY:*
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  • PAST SURGERIES: Have you had any surgeries?*
  • List of Any Past Surgeries:
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  • FAMILY HISTORY: Do any of your family members suffer from?*
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  • SOCIAL HISTORY:*
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  • Any Problems or Disruption with?*
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  • List What Medicines or Drugs allergic to, and your reaction:
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  • DO YOU TAKE ANY MEDICATIONS or SUPPLEMENTS?*
  • PRESENT MEDICATIONS: Prescribed Medicines & Over-the-Counters
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  • Have you tried any drugs in the past for your problem?*
  • List any drugs used in the past for your problem:
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  • GENERAL HEALTH QUESTIONS: Do you have any problems with
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  • Date*
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