SUPPLEMENT & PROBLEM FORM

    Please take a moment to detail your specific health concerns for Dr. Sharif so that he may be able to better serve you.

    1) Health concern #1:


    2) Health concern #2:


    3) Health concern #3:

    NOTE:If you have OTHER health concerns you would like to discuss with Dr. Sharif, list them all on a second page. Typed-up would be much preferred to hand-written.

    PLEASE PROVIDE A LIST OF ALL OF YOUR DRUGS & SUPPLEMENTS:
    DRUG NAME HOW OFTEN?

    NOTE: Please list your own supplements plus the ones Dr. Sharif has prescribed for you, ideally two separate lists. The items listed here are almost definitely going to change visit after visit. Therefore, please fill this form out every time. This will only help you and Dr. Sharif be able to better work together in order to help you with your health concerns.

    SUPPLEMENT NAME HOW MANY AND HOW OFTEN?