PLEASE NOTE: This section of the medical history contains questions that may be of a very personal nature and highly confidential aspect of your health. While we treat all information in your medical chart as confidential records, this section of the questionnaire is filed separately from the general medical data. It can be released only upon written consent from you for psychiatric, mental health and substance abuse records.
The following sets of questions are to help us identify problem areas that may be difficult to discuss. Select yes or no to each question and discuss any yes answers with your physician, nurse or mental health practitioners.