6. Health Information
D) Do you, or any family member listed in Section 5, take any medicine(s), drugs, pills or herbs, or require shots? X Yes _ No
If you checked any itesm in Question C or answered “yes” to Question D, please complete the following (use additional application form, if necessary):
| Name of Person | Condition | Dates Diagnosed and Treated |
Type of Treatment/ Names of Medications |
Current or Further Treatment? |
| Brian J. | Basil | |||
| Brian J. | Sage |
Well, they asked what herbs I was on.
