Medical History Addendum
To be completed if you will be working with a psychiatric or medical provider at Networks, Inc.
Date of Birth
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?
Which family members?
Neurologic (Parkinson's, head injury, stroke, etc.)
Eye conditions (blindness, glaucoma, cataracts)
Nose, mouth, throat condition
Lung/respiratory condition (asthma, chronic cough, chronic obstructive lung disease, breathing problems, etc.)
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.)
Muscle or bone conditions
Restless leg syndrome/periodic limb movement disorder
Abnormal sleep related behaviors (tooth grinding, sleep walking, night terrors, etc.)
Low blood count (anemia)
Bleeding or clotting problems
Major weight loss or gain
Unexplained death before the age of 40
Your Preferred Pharmacy
Please list the name & town.
Pharmacy Phone Number
Please share information you believe to be relevant to your treatment and the conditions you noted above.
Should be Empty: