Medical History Form v.CTB

Medical History
Full Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is your date of birth?

MonthDayYear
Email
example@example.com
Phone Number*
What is your current occupation?
Check all the difficulties that apply to you:*

AnxietyDepressionAttention problemsAnger problemsAddictionsTraumatic events, current or pastRelationship stress/ Social difficultiesWork stressStress related to medical problemsLife transitionSleep problemsMemory problemsAutoimmune disordersMigraines or headachesDigestive problems, stomach aches, bowel issuesCovid-related health complicationsOther
Name of current mental health therapist
Phone number of current therapist
Email address for current therapist (we need this to provide important info to them)
Have you been in mental health treatment previously? If so, when and what was the focus at that time?
What medications, if any, do you take? Include who prescribes them.
Do you use or do you have history being admitted to a psychiatric hospital?*
Do you have a history of suicidal behavior?*
How often do you consume alcohol?*

Most days2-3x per weekAbout once a weekMonthlyOccasionallyNever
How often do you use marijuana?*

Most days2-3x per weekAbout once a weekMonthlyOccasionallyNever
Do you use or do you have history of abusing pills or other street drugs?*
Have you ever had a concussion or a head inury?*
Have you ever been diagnosed with a seizure disorder?*
Have you ever had brain surgery?*
Which provider are you scheduled with at WellBeing CNY
Should be Empty: