Clone of Medical History Form v.CTB

Full Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What is your date of birth?

MonthDayYear

Email

example@example.com

Phone Number

Format: (000) 000-0000.

What is your current occupation?

Check all the difficulties that apply to you:

Name of current/ last mental health therapist

Phone number of current/ last therapist

Email address for current/last therapist

Have you been in mental health treatment previously? If so, when and what was the focus at that time?

What medications, if any, do you take? Include who prescribes them.

Do you use or do you have history being admitted to a psychiatric hospital?

Do you have a history of suicidal behavior?

How often do you consume alcohol?

How often do you use marijuana?

Do you use or do you have history of abusing pills or other street drugs?

Have you ever had a concussion or a head inury?

Have you ever been diagnosed with a seizure disorder?

Have you ever had brain surgery?

Which provider are you scheduled with at WellBeing CNY