If the form is not completed by the patient, please provide the name and relationship to the patient of the individual completing the form.
INSTRUCTIONS FOR COMPLETING
Please answer the following questions about your health and history. Although this form is lengthy, it is designed to be very thorough. Completing this information before your appointment will greatly assist the doctor to best use your assessment time with her/him by enabling a more detailed focus.
If referred by a specific physician, mental health care provider, or other specialist, please provide his/her name, specialty, and contact information below:
Have you noticed any of these additional symptoms? Please check those that apply to you.
Past Medical History
Please check all medical condition that you have or have had in the past:
Substance Use History
Education and Work History
Planning for Future Healthcare