Karrh Patient History Form

Karrh Patient History Form

Please be sure to fill out the entire form and press the "Submit" button at the end
Patient Name
Please complete the following:
Allergies
Medical History: (please list any medical problems, ex. Hypertension, diabetes etc.)
Surgical History: (please list any previous surgeries with dates)
Mental Health Hospitalizations: (list year and reason)
Family Psych History: (List any family mental health issues with relationship, ex. Depression, anxiety)
Family History of Suicide: (List any family members who have died by suicide)

Name of Pharmacy:
Pharmacy Address:
Phone

Current Medications: This form must be filled out completely and returned with your paperwork. Failure to bring the completed list WILL result in your appointment being rescheduled. If you do not know all the information requested or you are unable to complete the form, please contact your pharmacy as they can print a list of your medications for you. This is acceptable in place of this form.

	Medication Name (Include "extended release" if used)	Dosage (mg of each pill)	Directions (# of pills and times of day/frequency)	Medical Condition (why med is taken)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19

VITAMINS, SUPPLEMENTS, HERBS (list all above)
FEMALE PATIENTS -- BIRTH CONTROL

Oral contraceptive (list above)PostmenopausalMirena IUD (list above)Partner VasectomyDepo Provera (list above)NoneHysterectomy: Total Partial (ovaries not removed)Other
Should be Empty:

	Yes	No
Have you ever felt you should cut down on your drinking?
Have people annoyed you by criticizing your drinking?
Have you ever felt bad or guilty about your drinking?
Have you ever had a drink first thing in the morning to steady nerves or get over a hangover?

Karrh Patient History Form

Social History: