Birmingham Neuropsychology
Voice: (205) 329-7815, fax: 329-7816
Richard Azrin, Ph.D. Cheryl Millsaps, Ph.D.
Instructions: Please complete this form as accurately and completely as you can. Dr. Azrin will discuss your responses with you.
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Significant Symptoms:
Diagnostic Exams:
Medical History:
Habits
Activities of Daily Living:
Current Medications:
Alcohol or Substance Use:
Smoking/Vaping/Tobacco:
Psychological/Psychiatric
Please describe below if you have ever had any treatment for psychiatric/psychological difficulties
Family Medical History
Education:
Occupation/Vocational History:
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Social History:
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