Health problems.

			Describe	Treatment/Medication
Neurological:	❒ no	❒ yes:	_____________________	_______________________________________
Orthopedic:	❒ no	❒ yes:	_____________________	________________________________________
Metabolic:	❒ no	❒ yes:	_____________________	________________________________________
Digestive:	❒ no	❒ yes:	_____________________	________________________________________
Hormonal:	❒ no	❒ yes:	_____________________	________________________________________
Otorhinolaryngologic:	❒ no	❒ yes:	_____________________	________________________________________
Pneumological:	❒ no	❒ yes:	_____________________	________________________________________
Cardiac:	❒ no	❒ yes:	_____________________	________________________________________
Emotional/Psychic:	❒ no	❒ yes:	_____________________	________________________________________