MEDICAL HISTORY FORM | CONFIDENTIAL PATIENT INFORMATION 

Date *
Date
Name *
Name
Date of Birth *
Date of Birth
Address *
Address
Phone Number (Home) *
Phone Number (Home)
Phone Number (Mobile)
Phone Number (Mobile)
Emergency Contact Name *
Emergency Contact Name
Emergency Contact Phone Number *
Emergency Contact Phone Number
Referring Clinician Name *
Referring Clinician Name
Referring Clinician Phone Number *
Referring Clinician Phone Number
Primary Clinician Name *
Primary Clinician Name
Primary Clinician Phone Number *
Primary Clinician Phone Number
Therapist's Name (if different from above)
Therapist's Name (if different from above)
Therapist's Phone Number
Therapist's Phone Number
Please list the names, doses and frequency of all medications (including over-the-counter medications) you're currently taking.
Do you currently suffer from suicidal thoughts? *
Please describe all known allergies, as well as the adverse reactions they cause.
Please describe your current & past medical problems.
Please list the dates and descriptions of all past surgeries.
Any history of problems with anesthesia for you or anyone in your family? *
Please describe any emergency room admissions in the past 3 months.
History of difficult IV stick/blood draw? *
HISTORY OF SUBSTANCE USE
For each substance listed, please describe how much you use, how often you use it, when you used it last and for how many years you have been using it.
REVIEW OF SYSTEMS
Please check off the various symptoms you are experiencing for each bodily system.
General *
Skin *
Head *
Ears *
Eyes *
Nose *
Throat *
Neck *
Breasts *
Respiratory *
Cardiovascular *
Gastrointestinal *
Urinary *
Vascular *
Musculoskeletal *
Neurologic *
Hematologic *
Endocrine *
Psychiatric *