Home Remedies Nipple Discharge

_____ Nipple discharge Respiratory _____ Cough/wheeze _____ Coughing up blood Gastrointestinal _____ _____ movement Fainting MEDICATIONS: Prescription and non-prescription medicines, vitamins, home remedies, birth control pills, herbs, etc.

___ Breast lump / pain / nipple discharge ___ No problems Ears/Nose/Throat ___ Nosebleeds, home remedies, birth control pills, herbs, inhalers, etc. Use the back of this form if you need more room and let us know you wrote there. If you have guns in your home, are they locked up?

____ Nipple discharge ____Recent back pain In the past month, have you had little interest or pleasure in doing things, felt down, depressed or hopeless? Yes No MEDICATIONS: Prescription and non-prescription medicines, vitamins, home remedies, birth control pills, herbs, etc.

Medical History Form. Medications: All prescription, non-prescription, vitamins, home remedies, or herbal medication . Name Dose (ex: mg/pill)