Patient Medical History
Name:
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First Name
Middle Name/Initial (Not required)
Last Name
Date of Birth:
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Month
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Day
Year
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Today's Date:
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Month
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Day
Year
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Gender:
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Male
Female
Non-Binary
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Medical History
Drug allergies:
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Surgical history:
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History of Significant Injuries or Accidents:
Please check beside any illness/medical condition you have now or have had in the past:
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Arthritis
Blood Disorders
Bowel Problems
Cancer
Chest Pain
Chronic Pain
Diabetes
Glaucoma/Vision Problems
Heart Attack
Hepatitis
Liver Disease
Lung Disease/Breathing Problems
Migraines
Seizures/Epilepsy
Stomach Problems
Stroke
Thyroid Disease
Ulcer
None of the Above
Please list any chronic health conditions not shown above:
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Current medications:
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Family History:
Medical History (i.e. Mother - Diabetes; Paternal Grandfather - Cancer):
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Psychiatric History (i.e. Father - Alcohol use disorder; Maternal Aunt - Bipolar Disorder:
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Psychiatric History:
Past or current psychiatric diagnoses:
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Past admissions to psychiatric hospitals or residential treatment centers:
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Please list any history of suicide attempts or self-harm:
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Please list any history of problematic substance abuse:
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Current psychiatric medications including any medication for substance use disorder:
*
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Social History:
History of abuse, assault or neglect:
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History of learning differences:
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Please describe your current housing situation:
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Please list your current family or support structure:
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Highest level of education:
Employment status:
Military history:
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