AMERICAN MEDICAL QUESTIONNAIRE

By Shelby Pinkham

Date of appointment:

What problem are you being seen for today?
How long have you been experiencing this displeasure?
Why are you crying?
What color would you use to describe your pain?
Do you drink frequently?
How do you personally define frequency? What drugs are you interested in trying?
Describe the WebMD search results that best align with your symptoms:

Medical History: Are you under treatment or have you been treated for any of the following?

Do you have a family history of? (Circle all that apply)

Please check any box that applies to you now or in the past 6 months:


Shelby Pinkham is a queer, Chicanx poet who has called three Central Valley cities her home: Bakersfield, Stockton, and now Fresno. She has served as an assistant editor for The Normal School literary magazine, as an assistant editor for Rabid Oak, and as an editorial assistant for the Philip Levine Prize for Poetry book contest. She currently studies poetry as a second-year MFA student at Fresno State. Her work is forthcoming in bee house journal.