MEDICAL HISTORY FORM

Primary Insurance

We are only in-network with Blue Cross Blue Shield PPO.
Do you have insurance?
Primary Insurance Company:
Subscriber Name:

First NameMiddle NameLast Name
Subscriber Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Subscriber Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Subscriber Gender

Other
Subscriber Phone:

Area CodePhone Number
Insurance ID:
Group Number:
Secondary Insurance

Our office does not bill to secondary insurance, but we do keep it on file for our records. If you have Medicare, it is important to note this below as an additional form will be required by Medicare indicating that you are aware that you may not seek reimbursement from Medicare for any services provided by our office.
Secondary Insurance Company:
Subscriber Name:

First NameLast Name
Subscriber Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Subscriber Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Subscriber Phone:

Area CodePhone Number
Insurance ID:
Group Number:
I hereby authorize Lott Behavioral Health, Ltd. to furnish my insurance company all information that may be requested concerning claim processing. I am financially responsible for charges not covered by my insurance company. I hereby assign to Lott Behavioral Health, Ltd. all monies to which I am entitled for expenses relative to the services received. I understand that if I am self-pay or have out-of-network insurance that payment is due in full at the time of service and my insurance company will need to reimburse me personally.
Patient Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent or Legal Guardian Signature if applicable
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Family History

Extended family psychiatric problems past and present

Rows	Health & Psychiatric	Age(s) at death	Cause
Father
Mother
Siblings
Children

Maternal Relatives:
Paternal Relatives:

SUBSTANCE MISUSE

Rows	Specify (if necessary)	Age when you first used this:	How much & how often did you use this?	How many years did you use this?	When did you last use this?	Do you currently use this? (Y/N)
ALCOHOL
CANNABIS: Marijuana, hashish, hash oil, THC
STIMULANTS: Cocaine, crack
STIMULANTS: Methamphetamine--speed, ice, crank
AMPHETAMINES/OTHER STIMULANTS: Ritalin, Adderall, Dexedrine, etc.
BENZODIAZEPINES/TRANQUILIZERS: Valium, Librium, Halcion, Xanax, Diazepam, etc.
SEDATIVES/HYPNOTICS/BARBITURATES: Amytal, Seconal, Dalmane, Quaalude, Phenobarbital
HEROIN
STREET OR ILLICIT METHADONE
OTHER OPIOIDS: Tylenol #2 & #3, Vicodin, Norco, Percocet, Opium, Morphine, Fentanyl, Dilaudid, etc.
HALLUCINOGENS: LSD, MDA, DAT, mescaline, peyote, mushrooms, ecstasy (MDMA), nitrous oxide, etc.
INHALANTS: Glue, gasoline, aerosols, paint thinner, poppers air duster, etc.
TOBACCO, NICOTINE, VAPING, AND OTHERS: Specify

Signature

MEDICATION LIST

What medications are you currently taking? (Please list below)

Rows	Name of Medication	Dose	Qty / Times Per Day	Prescribing Doctor
1
2
3
4
5
6
7
8

Do you have any allergies to any medications? (If YES please list)
If yes, please list:
Preferred Pharmacy Name:
Pharmacy Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Previous Psychiatric Medications You Have Tried Before (please list):

Appointment Reminders
The office currently uses an automated system to send appointment reminders. These reminders are provided as a courtesy only and do not waive or alter the office cancellation policy.

At this time, the system sends reminders by email and you may also select reminders by text message or automated phone call. Reminder options may change in the future.

Because reminders are sent through a third-party service, we cannot guarantee delivery. Patients should not rely solely on appointment reminders to keep track of scheduled appointments.
Methods of contact for appointment reminders (email and either text OR voice):
Phone Number

Area CodePhone Number
Email
example@example.com
Confirm Email
example@example.com
Additional Information:
Emergency Contact Name:

First NameLast Name
Relationship:
Emergency Contact Phone Number

Area CodePhone Number
I consent to receive emails, calls, or text messages from the practice at my phones and any number forwarded or transferred to/from that number or emails to receive communication as stated above. I understand that this request to receive emails, calls, and text messages will apply to all future appointment reminders unless I request a change in writing. I further understand and agree that the phone numbers and email may be used for other practice communications. The practice does not charge for this service, but standard data rates may apply as provided in my plans. I understand that although the systems use secure communication methods, no electronic communication can be completely secure from all unforeseen circumstances.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Patient Information

Primary Insurance

Secondary Insurance

MEDICAL HISTORY

Family History

Systems Review

WOMEN'S REPRODUCTIVE HEALTH HISTORY

SUBSTANCE MISUSE

MEDICATION LIST

Appointment Reminders