Medical Assessment - Medications and Allergies
(Form 6 of 6)

CURRENT: Medications You Are Now Taking
(including any over the counter medications, hormones and birth control pills):

PAST: Have you ever used any of the following medications on a regular basis?
(If ‘YES’, when, and did it work?)

(Including medications, x-ray dye, latex, tapes, foods, etc.)

Our Location

Erlanger Medical Mall
979 East Third Street
Suite C-0630
Chattanooga, TN 37403

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More Info

If you need additional information, please call us at (423) 267-5677, or send an e-mail to