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Other medical problems (please specify):
Previous Surgeries:
Previous Hospitalizations (other than psychiatric):
Medication Allergies/:Other Allergies:Please put N/A if none.)
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Current Medications (Other than psychiatric medications) Name, Dose, Indication.
Are any over-the-counter medications taken regularly?
For Female Patients: Any plans for pregnancy in the near future? (Please notify me if this changes) Birth Control/Contraceptive type (if any):
Please provide any details.
Please provide any additional information here.
Previous Mental Health Treatment:
Previous Psychiatric Diagnoses:
Previous Psychiatrists:
Previous Therapists:
Current Therapist:
Have you ever had neuropsychological testing? If yes, give results, provider name & date:
Current Psychiatric Medications, Medication, Dosage, and Date Started (Please respond N/A if none):
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Previous Medications (use section below if necessary): Please respond N/A if none):
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Previous Psychiatric Hospitalizations (Hospital Name, Dates, Reason):
Previous Intensive Outpatient Programs or Partial Hospitalization Programs(Programs, Dates):
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Any history of abuse as a child?Any previous legal charges?Are there any guns/weapons in the home and if so, is it locked up?Any significant stressors or traumas to you or your family?
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If there is a second home (such as due to divorce or separation) please list members of secondary household. Include-Name, Age, Grade/School, Relation To Patience:
EDUCATION/EMPLOYMENT HISTORY: In what city/cities did you attend grade/high school/College?Did you earn a high school degree?Year?
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Employer, Position,Length of time at current employer, Any other pertinent information?:
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First/Middle Name
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Last name
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Multi-line address
Country/Region
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Address
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City
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Zip / Postal code
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Home Phone
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Cell Phone
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Work Phone
Birthday
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Month
Day
Year
Emergency Contact
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Emergency Cell Phone
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Emergency Work/Home Phone
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Relationship
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Preferred Pharmacy & Location
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Pharmacy Number
Reason for consultation, who referred you? What was their concern? What is your primary concern? When did you first become aware of concerns?
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Have these concerns caused problems in any areas of your life (relationships? school/work or hobbies?)
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Primary Care Provider Name:
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