Medical History Application Form

Medical History for Application

Past Psychiatric and Mental Illness History

Examples of Antidepressant medications are: Prozac, Zoloft, Luvox, Paxil, Celexa, Lexapro, Effexor, Cymbalta, Wellbutrin, Remeron, Serzone, Anafranil, Pamelor, Tofranil, Elavil.
Examples of Antipsychotics/Mood Stabilizer medications are: Seroquel, Zyprexa, Geodon, Abilify, Clozaril, Haldol, Prolixin, Risperdal, Sedative/Hypnotics Ambien, Sonata, Rozerem, Restoril, Desyrel.
Examples of Mood Stabilizer medications are: Tegretol, Lithium, Depakote, Lamictal, Topamax.
Examples of ADHD medications are: Adderall, Concerta, Ritalin, Strattera.
Examples of Antianxiety medications are: Xanax, Ativan, Klonopin, Valium, Tranxene, Buspar.

Family Psychiatric and Mental Illness History

Substance Use