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Medical Questions
Please List any allergies List medications you are currently taking
What is your primary health complaint?
I have (check all that apply):
anxiety  neck pain  back pain  endometriosis  migraines  fibromyalgia  radiation down arms
radiation down legs  had surgery for this condition    
tried physical therapy modalities and other medication without success 
other  
I am aware that the medication may be addicting, deny receiving same medications from other physicians, state that this medication is for my own use, and affirm that the medication is the only way for me to lead a normal and productive life.
Type "yes" to agree.
I am informed that the prescription will be transmitted via electronic means to the pharmacy and has no objections.  
Type "yes" to agree.
I deny having a history of kidney or liver problems.
Type "yes" to agree.
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