• NCHH - Medical History Questionnaire

    NCHH - Medical History Questionnaire

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  • 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.  

  • 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.  

  • Please answer the following questions about past and current medical conditions. Do you have now (CURRENT) or have you had (PAST) history of any of the following conditions? 

    SELECT:  YES or NO 

  • DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure—Adult (18 or older)

    Instructions: The questions below ask about things that might have bothered you. For each question, circle the number that best describes how much (or how often) you have been bothered by each problem during the past TWO (2) WEEKS.

  • DSM-5 Parent-Rated or Guardian-Rated Level 1 Cross-Cutting Symptom Measure—Adolescent - under 18 years old

    Instructions (to the parent or guardian of the patient): The questions below ask about things that might have bothered your child. For each question, circle the number that best describes how much (or how often) your child has been bothered by each problem during the past TWO (2) WEEKS.

  • Because alcohol use can affect health and mood, and interferes with certain medications and treatments, it is important that we ask you some questions about your use of alcohol.  Your answers remain confidential, so please be as accurate as possible.  Try to answer the questions in terms of 'standard drink'.

     

  • If you are finished with this Medical History form, CLICK on the SUBMIT button to complete;  it will not submit if you did not complete the required sections (scroll back to see what is missing).  Push Save to save your information and return to it later.   

  • Should be Empty: