MEDICATION LIST & Lifestyle HX

RESTORE BEHAVIORAL HEALTH

1314 EAST SONTERRA BLVD; SUITE 2208

SAN ANTONIO, TEXAS 78258

210 858 -1900 phone

210 745-4525 fax
MEDICATION LIST & Lifestyle HX

PLEASE PROVIDE AN UPDATED, ACCURATE AND COMPLETE LIST OF ALL YOUR CURRENT MEDICATIONS and ANSWER THE LIFESTYLE QUESTIONS BELOW.
*Type your Name here

First NameMiddle NameLast NameSuffix (Jr, Sr, III, ect)
Patient DOB:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient Phone Number

Area CodePhone Number
Patient Medications

Be work with your prescribing physician to review your current medications and dosages on a regular basis. Please list below all current medications, over-the-counter, diabetic, dietary supplements and vitamins.
Primary Care Physician Name:

First NameLast Name
PCP Phone:

Area CodePhone Number
Psychiatrist Name:

First NameLast Name
Psychiatrist Phone:

Area CodePhone Number
Other Specialist Name:

First NameLast Name
Other Specialist Phone:

Area CodePhone Number

Please List All Current Medications that you (or your child) are taking:

Patient Tobacco/Alcohol/Caffeine/Nicotine/ Cannabis/Other Substance Usage
Tobacco/Nicotine/Vaping Usage:
Date I Quit Smoking:

MonthDayYear
# Cigarettes per day?
Alcohol Consumption
Cannabis Consumption
Other Drug Consumption (overuse of prescription medications, use of illicit drugs)
Caffeine Consumption
I would describe my Quality of Sleep as:
In general, it takes me _____ minutes to fall asleep at night:
On average, I wake up in the middle of the night
The average number of hours of sleep per night that I get is:
I have noticed the following about my Appetite/Weight over the last year:
Current Weight
Current Height
Change in weight over the last year: blanks .
Name of Person Completing this Form:

First NameLast Name
Relation to Patient:
Today's Date

MonthDayYear
Type Security Code Below
Should be Empty:

Patient Medications