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SRN New Patient Packet Medical

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View Open Positions
Medical New Patient Paperwork
Gender (select)
Race (select)
Address
Address
City
State/Province
Zip/Postal

Person to notify in case of emergency:

SYMPTOMS:

What are your symptoms / what bothers you most (in priority order)?
Please indicate how much each symptom bothers you:
(1=A little; 2=Moderate; 3=A lot; 4=Extremely, place number after the symptom)

Family History of mental health problems:

 

 

OTHER SYMPTOMS: (select Yes or No)

1. There are weeks that I feel charged with energy and require almost no sleep.
2. I have had anxiety attacks that come on me suddenly and unexpectedly
3. I have a strong urge to repeat certain acts over and over.
4. Disturbing thoughts come into my mind that I cannot get rid of.
5. I sometimes have trouble controlling my anger.
6. I have experienced a traumatic event and have distressing memories of the event.
7. I periodically injure myself on purpose.
8. I think about suicide or have made a suicide attempt.

 

9. I am afraid of certain places, objects, or animals and go out of my way to avoid them.
10. I get unusually fearful in social situations.
11. As a child I was frequently in trouble for fighting, lying, stealing or skipping school.
12. I have had an eating disorder

PERSONAL HABITS:

Are you willing to discontinue all alcohol use if you participate in a study?
When was the last time that you used recreational drugs (e.g. marijuana, cocaine, methamphetamine, etc.)? Please select:

 

LEGAL HISTORY:

Are you currently involved in a legal dispute?
Have you ever been arrested?

EDUCATION AND WORK HISTORY

Level of Education
While attending school, what grades do/did you typically earn?
Are you currently employed?
Have you ever served in the military?

RELATIONSHIP HISTORY:

Current method of birth control (check all that apply):
Do you have children?
Thank you for completing this confidential form. You will have the opportunity to discuss your answers
when you meet with your doctor.
For staff use only: Date reviewed with clinician:___________________________
All entries in __________ink made by _______________upon review with the patient

Medical History Questionnaire

Please check yes or no for
each condition listed below
Ear, Nose, Throat Disease?
Yes No
Eye Disease?
Checkboxes

 

Thyroid Disease / Goiter?

Checkboxes
Heart Disease?
Checkboxes
High Blood Pressure?
Checkboxes
High Cholesterol?
Checkboxes
Lung Disease?
Checkboxes
Diabetes?
Checkboxes
Liver / Gallbladder Disease?
Checkboxes
Stomach / Intestinal Disease?
Checkboxes
Kidney / Bladder Disease?
Checkboxes
Prostate Disease?
Checkboxes
Breast Disease?
Checkboxes
Uterine / Ovarian/ Cervical Disease?
Checkboxes
Epilepsy / Seizures/Stroke or TIA?
Checkboxes
Neurological Disease?
Checkboxes
Bone or Joint Disease?
Checkboxes
Skin Disease?
Checkboxes
Psychological Problems?
Checkboxes
Blood Disease?
Checkboxes
Cancer or Tumors?
Checkboxes
Current method of birth control?
Checkboxes
Other?
Checkboxes

SURGERIES or HOSPITALIZATIONS:

ALLERGIES: Please list all including environmental, food, & medication

MEDICATIONS: What over-the-counter or prescription medications, including vitamins and herbal preparations, have you taken in the last 3 months?

Cont’d?