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
Mental Health Clinician Name *
Mental Health Clinician Name
If applicable
If applicable
If applicable
Do you currently suffer from suicidal thoughts? *
Please list, to the best of your ability, the dates of any past suicide attempts.
Please list your current medications, the dosage prescribed, and the frequency with which you take it.
Please describe all known allergies, as well as the adverse reactions they cause.
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.
GENERAL MEDICAL HISTORY
Please describe your history of medical problems in as much detail as possible.
Please list the dates and nature of any past surgeries.
Please list the dates and nature of any emergency room visits in the past 6-months.
Please list the dates and nature of any in-patient admissions in the past 6-months.
History of electroconvulsive therapy? *
History of hallucinations? *
History of difficult IV stick/blood draw? *
REVIEW OF SYSTEMS
Please check off the various symptoms you are experiencing for each bodily system.
Eyes *
Respiratory *
Cardiovascular *
Urinary *
Vascular *
Neurologic *