Northwest Alabama Treatment Center

Northwest Alabama Treatment Center

4204 Edmonton Drive, Bessemer AL 35022

Phone-205-425-1200 / Fax-205-425-9606

New Patient Form

First Name: ______Today’s Date:______

Last Name:______

Nickname:______

Date of Birth:______

Home phone:______

Cell phone:______

Street:______

City/State:______

Zip:______

Social Security Number:______

Driver’s license state and number:______

Sex: Male or Female

Choose one:SingleMarriedWidowedDivorcedSeparated

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Primary Source of Income: ______

Amount per month: $______

Secondary Source of Income:______

Amount per month: $______

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Health Insurance Information

Medicaid: Yes or No

Other Health Insurance:______

Primary Care Provider:______

Pharmacy Name:______

Pharmacy Number:______

Emergency Contact Name / Relationship:______

Emergency contact number:______

Confidential Health History: (please explain. If none, just write NONE)

Neurological (ex: sleep disorders, night sweats, head injury, headaches, fainting, dizziness, bipolar, anxiety, depression, PTSD, etc.) ______

______

Dermatological (ex:eczema, herpes- oral or STD, dry skin, thin skin, bruise easily)

______

Eyes/Ears/Nose/Throat (ex: vision impairment, ear pain, ear infection, bloody nose-multiple, hoarse)

______

Respiratory (ex: COPD, tuberculosis, slow/shallow breathing, asthma, allergies)

______

Cardiovascular (ex: High blood pressure, CHF, dysrhythmias, mitral valve prolapse, tachycardia (fast), bradycardia (slow), pacemaker, etc.) ______

______

Gastrointestinal (ex: indigestion, ulcers, nausea/vomiting, constipation, diarrhea, gas/bloating)

______

Liver/Pancreas (ex: cirrhosis, hepatitis B or C, HIV, fatty liver, Diabetes Type I or II)

______

Urinary (ex: STD’s, incontinence, blood in urine, urinary pain)

______

Musculoskeletal (ex: arthritis, fractures/breaks, dental issues, muscle weakness/numbness)

______

Women only

Last OB/Gynvisit:______

Last pap smear done:______Normal / Abnormal

Do you use contraception:______What kind:______

Periods: Regular IrregularExplain:______

Number of pregnancies:______Miscarriages:______

Currently pregnant:______How far along:______

Current Medications:______

______

______

Medication Allergies:______

Environmental allergies: ______

Family Health/Addiction History (ex: mother-breast cancer, father- heart attack, brother-uses heroin)

______

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Been in Substance Abuse Treatment Before: Yes or No

Where:______

When: ______

For how long:______

Drug of Choice: ______Route: (mouth, IV etc.) ______

Symptoms of withdrawal: (circle or star *) craving, irritability, nausea/vomiting, sweating, runny nose, yawning, diarrhea, aching limbs, tiredness, fatigue, insomnia, abdominal pain, chills/fever

Do you smoke/vape/use tobacco: ______How much:______

Do you drink alcohol: ______How much: ______

Any other significant illnesses, injuries, or other concerns regarding your health: ______

______

______

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New Patient Sign Here:______

To make an intake appointment, please call our direct line, 205-425-1200 between the hours of 5am and 12:30pm. Our office closes at 12:30pm Monday through Friday. If you are unable to call during those hours, please leave a message and we will return your call promptly.

Please email this completed form to  or print out and bring with you to your first appointment.