Patient Information

Confidential Patient Information

Complete all sections
A. PATIENT INFORMATION
Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Info
What is the best number to reach you?
Additional Info
Sex
Marital Status
Handedness
Level of Education Completed
Majors
Any difficulties (behavioral/academic) while in school
Ever been diagnosed with a learning disability?
Employment
Disabled
Retired
Annual Income
B. REFERRAL INFORMATION
Who referred you?
Reason for referral
Were you injured on the job (Workman's Comp)?
Are you represented by an attorney?
Describe the problems you've been having and for how long?
What do you hope to learn from this visit/or evaluation?
C. MEDICAL HISTORY
Do you have any medical conditions?
e.g. high blood pressure, cancer, diabetes, etc.
Check all that apply
Have you ever had a head injury?
If YES, did you lose consciousness or black out?
If YES, answer the following:
Do you take any medications?
If YES please list ALL Medications
D. PSYCHIATRIC/EMOTIONAL HISTORY
Check all that apply
E. DRUG/ALCOHOL USE
Do you drink alcohol?
Do you use illicit drugs?
If YES, name and time.
Any family history of alcohol or drug use?
F. HISTORY OF LEGAL PROBLEMS OR ARRESTS
Have you ever been arrested?
If YES, please explain
Signature
Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Confidential Patient Information