New Patient Form

New Patient Intake

PSYCHIATRIC AND MEDICAL HISTORY FORM
Patient's Name
Address
Ok to leave confidential message?
Marital Status
Student Status
MM slash DD slash YYYY
feet inches
Employment
Employer
Occupation
For how long?
 
Family Physician
Date
Phone
Fax
Is it OK to contact them?
 
Currrent Therapist(s)
Date
Phone
Fax
Is it OK to contact them?
 
Past Therapist(s)
Date
Phone
Fax
Is it OK to contact them?
 
Is it ok to leave a message?
Emergency Contact
Name
Phone
Ok to leave message?
 
Emergency Contact #2
Name
Phone
Ok to leave message?
 

Psychiatric History

List any past psychiatric care and medications prescribed:
Date
Psychiatrist (Name, City, State)
Diagnosis
Medications prescribed
 
List any past psychiatric hospitalizations or substance abuse treatment and their dates:
Date
Facility(Name, City, State)
Type of Treatment
 
Current or past alcohol use
How Often
How much
Comments
 
Current or past drug use
How Often
How much
Comments
 
Current or past tobacco or nocotine use
How Often
How much
Comments
 

Medical History

Please check if you have been diagnosed with any of the medical conditions listed below:
List all medications, herbs and nutritional supplements you are now taking:
Medication, Herb or Supplement
Dose (MG's, etc)
Prescribed by
 
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Erin Cloke
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Telemedicine by Erin Cloke Psychiatric Services