APPENDIX H ●^585
CURRENT/PAST USE OF OVER-THE-COUNTER DRUGS (Indicate with “c” or “p” beside name of drug whether current or past use): Name Dosage How Long Used Why Prescribed
By Whom Side Effects/Results
CURRENT/PAST USE OF STREET DRUGS, ALCOHOL, NICOTINE, AND/OR CAFFEINE (Indicate with “c” or “p” beside name of drug whether current or past use): Name Amount Used^ How Often Used
When Last Used Effects/Produced
2 2506_Appendix_H_583-587.indd 585 506 _AppendixH 583 - 587 .indd 585 Any allergies to food or drugs? Any special diet considerations? 1 10/1/10 9:31:02 AM 0 / 1 / 10 9 : 31 : 02 AM