MEDICATION LIST & Lifestyle HX

RESTORE BEHAVIORAL HEALTH

1314 EAST SONTERRA BLVD; SUITE 2208

SAN ANTONIO, TEXAS 78258

210 858 -1900 phone

210 745-4525 fax
MEDICATION LIST & Lifestyle HX

PLEASE PROVIDE AN UPDATED, ACCURATE AND COMPLETE LIST OF ALL YOUR CURRENT MEDICATIONS and ANSWER THE LIFESTYLE QUESTIONS BELOW.
*Type your Name here*

First NameMiddle NameLast NameSuffix (Jr, Sr, III, ect)
Patient DOB:

MonthDayYear
Date
Patient Phone Number*

Area CodePhone Number
Patient Medications

Be work with your prescribing physician to review your current medications and dosages on a regular basis. Please list below all current medications, over-the-counter, diabetic, dietary supplements and vitamins.
Primary Care Physician Name:

First NameLast Name
PCP Phone:

Area CodePhone Number
Psychiatrist Name:

First NameLast Name
Psychiatrist Phone:

Area CodePhone Number
Other Specialist Name:

First NameLast Name
Other Specialist Phone:

Area CodePhone Number

Please List All Current Medications that you (or your child) are taking:

	Medication Name	Dosage Amount	#Taken Daily	Ordering Doctor	Condition
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Patient Tobacco/Alcohol/Caffeine/Nicotine/ Cannabis/Other Substance Usage
Tobacco/Nicotine/Vaping Usage:*

Yes, I Smoke DailyYes, Sometimes I SmokeNo, I Quit SmokingNo, I Never Smoked
Date I Quit Smoking:*

MonthDayYear
# Cigarettes per day?*
Alcohol Consumption*

I don't drink1-4 drinks/month1-2 drinks/day3-4 drinks/day5+ drinks/day
Cannabis Consumption*

NoneCurrently Not Using, Past Use OnlyDaily2-3x/week3-4x/week
Other Drug Consumption (overuse of prescription medications, use of illicit drugs)*

NoneCurrently Not Using, Past Use OnlyDaily2-3x/week3-4x/week
Caffeine Consumption*

I don't use caffeine1-4 cups/month1-2 cups/day3-4 cups/day5+ cups/day
I would describe my Quality of Sleep as:

PoorAverageGoodExcellent
In general, it takes me _____ minutes to fall asleep at night:

less than 15 minless than 30 min1-2 hoursMore than 2 hours
On average, I wake up in the middle of the night

NeverBriefly to use the bathroomOften, with difficulties falling back asleepMany times per night
The average number of hours of sleep per night that I get is:

2-3 hours3-4 hours5-6 Hours6-7 Hours8-9 HoursMore than 9 hours
I have noticed the following about my Appetite/Weight over the last year:

Same as usual, no significant changeWeight or Appetite LossWeight or Appetite GainVariable Appetite/WeightBinge EatingRestrictive EatingPurging
Current Weight
Current Height
Change in weight over the last year: blanks .
Name of Person Completing this Form:

First NameLast Name
Relation to Patient:
Today's Date*

MonthDayYear
Type Security Code Below*
Should be Empty:

MEDICATION LIST & Lifestyle HX

Patient Medications

Patient Tobacco/Alcohol/Caffeine/Nicotine/ Cannabis/Other Substance Usage