NCHH - Medical History Questionnaire

NCHH - Medical History Questionnaire
Patient's Full Name*

First NameMiddle NameLast Name
Patient's Preferred Name*
Patient's Date of Birth (DOB)*

MonthDayYear
Patient Email*
example@example.com
Please complete this questionnaire and submit to the office, prior to your scheduled appointment. This questionnaire is essential to your first appointment and the complete assessment of your mood. If this questionnaire is not completed prior to the visit, you will be asked to complete it during the initial visit.

Have any of the following relevant items with you for your first appointment:
1. A list of all of your medications (including all vitamins, and supplements that you take daily)
2. Any relevant discharge paperwork (from previous clinics, hospitals, or treatment programs, if applicable)
3. Any other relevant documents: Psychological testing, Laboratory reports, neuropsychological testing, Individual Education Plans (IEPs), Genetic Testing reports
We will do our best to review all relevant documents which you bring in the appointment, however, because of time-limits we may not be able to review everything during the initial evaluation. The review can occur outside an appointment, OR during another appointment.

If you have a family member or guardian who is going to attend the appointment and wants to share information, please inform our staff so that they can schedule extra time for the appointment. It is possible that we may not be able to accommodate more than one other person in the office.

All patients under 18 years of age, will need to have a parent or guardian present at the appointment as we will include them in the process. A parent or guardian must legally consent to care when the patient is under 18 years of age.

In addition, I would like to remind you to please make sure you are aware of the parking options at our offices. In Nashville, you will need to bring change or some form of payment for the parking meters or the parking lots nearby our office.
If this questionnaire is completed by someone other than the patient, what is your relationship with the patient?
In a typical week, approximately how much time do you spend with the patient?
Patient's Preferred Pharmacy Name/Location*
Preferred Pharmacy Phone
Preferred Pharmacy Fax

CURRENT MEDICATIONS:

Please list your CURRENT prescription and non-prescription medications, vitamins, home remedies, birth control pills, and herbal supplements. Past medications are listed next.
List your current medication, why you take the medication (what condition it treats), and what dosage you take and how many times the medication is taken per day (write "NONE" if no medications or supplements are taken)*
List your allergies or reactions to medications/foods/or other things (write NONE if no allergies)*
For example: Pencillin = Rash all over; Pain medications = make me nauseous
Who is your primary care clinician/ internist / general practitioner? Write "NONE" if you don't have a current doctor, we can make a referral if needed*
Can we contact your Primary doctor?*

YESNOI have no current doctor
Primary doctor Phone number if known
Who is your therapist? Write "NONE" if you have no current therapist, we can make a referral if needed. *
Can we contact your therapist?*

YESNOI have no current therapist
Therapist Phone number if known
Are there specialists involved in your care?*
Type the names of specialists or say NO
Can we contact your Specialists?*

YESNOThere are no specialists involved in my care
Phone numbers, if known