Medical History Addendum
To be completed if you will be working with a psychiatric or medical provider at Networks, Inc.
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Review of systems: Have you or anyone in your family (parents, siblings, children, maternal or paternal grandparents, aunts, uncles, cousins) been treated for any of the following conditions?
You
Family
Which family members?
Comments
Headache
Head injury
Neurologic (Parkinson's, head injury, stroke, etc.)
Blackouts
Dizziness/fainting
Memory issues
Heart disease
Irregular heartbeat
Stroke
Eye conditions (blindness, glaucoma, cataracts)
Hearing problems
Thyroid conditions
Sleep apnea
Nose, mouth, throat condition
Lung/respiratory condition (asthma, chronic cough, chronic obstructive lung disease, breathing problems, etc.)
Skin conditions
Kidney disease
Urinary tract conditions
(Female only) Gynecological issues (endometriosis, problems related to menstrual cycle, etc.)
(Females only) Date of last menstrual period
(Female only) Pregnancy related issues (Miscarriages, abortions, ectopic pregnancy, premature deliveries, etc.)
Sexual problems (problems with sex organs, desire, sexual dysfunction, STD's, etc.)
Gastrointestinal condition (inflammatory bowel, irritable bowl, reflux, celiac disease, etc.)
Liver, pancreas conditions (hepatitis, pancreatitis, etc.)
Diabetes
Muscle or bone conditions
Restless leg syndrome/periodic limb movement disorder
Abnormal sleep related behaviors (tooth grinding, sleep walking, night terrors, etc.)
Chronic pain
Growths, cancer
Low blood count (anemia)
Bleeding or clotting problems
Hospitalizations
Major surgery
Major injuries
Major weight loss or gain
Physical limitations
Unexplained death before the age of 40
Your Preferred Pharmacy
Please list the name & town.
Pharmacy Phone Number
-
Area Code
Phone Number
Notes
Please share information you believe to be relevant to your treatment and the conditions you noted above.
Submit
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