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Medical History Application Form
Medical History for Application
Name
*
Past Psychiatric and Mental Illness History
Have you been diagnosed with or treated for:
*
Bipolar Disorder
Depression
Anxiety
Anger
Violence
Suicide
Schizophrenia
Post-traumatic Stress Disorder
Alcohol Abuse
Other Substance Abuse
None
Have you ever had Outpatient or Inpatient treatment?
*
Yes, Inpatient
Yes, Outpatient
No, I have never received treatment
If yes, please describe when, by whom, and nature of treatment. Reason, Dates, Treatment, By Whom.
Have you ever received treatment for Psychiatric Care or Mental Illness?
*
Yes
No
If yes, Please describe for what reason, when and where. Reason, Dates, Hospitalized Where?
Have you ever been prescribed psychiatric or mental illness medications?
*
Yes
No
Antidepressants- Please indicate the dates, dosage, and how helpful they were.
Examples of Antidepressant medications are: Prozac, Zoloft, Luvox, Paxil, Celexa, Lexapro, Effexor, Cymbalta, Wellbutrin, Remeron, Serzone, Anafranil, Pamelor, Tofranil, Elavil.
Antipsychotics/Mood Stabilizers- Please indicate the dates, dosage, and how helpful they were.
Examples of Antipsychotics/Mood Stabilizer medications are: Seroquel, Zyprexa, Geodon, Abilify, Clozaril, Haldol, Prolixin, Risperdal, Sedative/Hypnotics Ambien, Sonata, Rozerem, Restoril, Desyrel.
Mood Stabilizers- Please indicate the dates, dosage, and how helpful they were.
Examples of Mood Stabilizer medications are: Tegretol, Lithium, Depakote, Lamictal, Topamax.
ADHD Medications- Please indicate the dates, dosage, and how helpful they were.
Examples of ADHD medications are: Adderall, Concerta, Ritalin, Strattera.
Antianxiety Medications- Please indicate the dates, dosage, and how helpful they were.
Examples of Antianxiety medications are: Xanax, Ativan, Klonopin, Valium, Tranxene, Buspar.
When did you last receive a mental health examination?
*
Less than 6 months ago
6 months ago
A year ago
More than a year ago
Never
Family Psychiatric and Mental Illness History
Has anyone in your family been diagnosed with or treated for:
*
Bipolar Disorder
Depression
Anxiety
Anger
Violence
Suicide
Schizophrenia
Post-traumatic Stress Disorder
Alcohol Abuse
Other Substance Abuse
None
If yes to any of the diagnoses above, please list below who was diagnosed and with what.
Has any family member been treated with a psychiatric or mental illness medication?
*
Yes
No
If yes, who was treated, what medications did they take, and how effective was the treatment?
Substance Use
Have you ever been treated for alcohol or drug use or abuse?
*
Yes
No
If yes, for which substances, where were you treated, and when?
How many days per week do you drink alcohol?
*
What is the least number of drinks you will drink in a day?
*
What is the most number of drinks you will drink in a day?
*
In the past three months, what is the largest amount of alcoholic drinks you have consumed in one day?
*
Have you ever felt the need to decrease the level of alcohol consumption? Has the level of alcohol consumption posed as problematic in your daily life?
*
Yes
No
Have people annoyed you by critizing your drinking or drug use?
*
Yes
No
Have you ever felt bad or guilty about your drinking or drug use?
*
Yes
No
Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover?
*
Yes
No
Do you think you may have a problem with alcohol or drug use?
*
Yes
No
Have you used any street drugs in the past 3 months?
*
Yes
No
If yes, which ones?
Have you ever abused prescription medication?
*
Yes
No
If yes, which ones and for how long?
Check if you have ever tried the following:
*
Methamphetamine
Cocaine
Stimulants (pills)
Heroin
LSD or Hallucinogens
Marijuana
Pain Killers (not as prescribed)
Methadone
Tranquilizers/Sleeping pills
Alcohol
Ecstasy
None
Other
Other
Submit
If you are human, leave this field blank.
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