All information requested refers to the identified patient
1) Please list any conditions or chronic illnesses you have (such as high blood pressure, diabetes, pregnancy, glaucoma, prostate problems, etc.) □ None
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2) Please list allergies or reactions to foods or medicines. □ None
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3) Please list all medicines or drugs being taken now prescribed by a doctor or dentist.
(Include what you take for chronic conditions, birth control, etc.) □ None
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4) Please list medicines or drugs you sometimes take that were bought without a prescription. (Such as aspirin, antacids, sleep medicine, allergy, cold medicine, vitamins, etc.) □ None
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5) Does the patient have any biological relatives - father, mother, brother, sister, aunts, uncles or grandparents (maternal or paternal) - that suffer any of the following conditions? Who?
□ Depression: ________________________________________ _________________________________
□ Bipolar Disorder: ______________________________________________________________________
□ Anxiety/OCD: _________________________________________________________________________
□ Psychosis/Schizophrenia: ______________________________________________________________
□ Alcoholism: __________________________________________________________________________
□ Substance Abuse: _____________________________________________________________________
6) Do you smoke?
□ Often
□ Sometimes
□ Never
7) Do you drink Alcoholic beverages?
□ Often
□ Sometimes
□ Never
Patient’s Name: _____________________________________________________________________
Signature of Patient or Parent: ___________________________ Date: _________________________