Confidential Patient Registration/Information for Adults
Before your first appointment, please fill out as much of this form as you can
Name:_________________________________ Age:____Sex:_____Birthdate________
Address:__________________________City:____________________Zip:___________
Social Security #_________________Employer:________________________________
Education:______Occupation:___________________Marital Status: S M D W
Phone H:______________Phone W:___________________Cell:___________________
Contact person in case of Emergency:___________________Phone:_________________
Do you have an e-mail address? If so, what is it:_________________________________
Who recommended our clinic to you?________________________________________
Family Members
Spouse
Children
Birth date Education Occupation
Health-Medical Information
Primary Care Physician:________________City___________Phone:________________
Last physical Exam:_____________Were results normal? ____yes ____ no If no, Please explain:_________________________________________________________________
Do you consider yourself to be in good physical health? ___Yes ___No Please explain any concerns about your health:______________________________________________
Psychiatric Information
Have you, or are you, currently being treated by a psychiatrist? ____ Psychologist _____
Social Worker _____When________ What are (or were) you being treated for?_______
_______________________________________________________________________
History of Depression?_____Anxiety?____Obessessions?______Other?_____________
Any Inpatient admissions?_____When_______Where____________________________
Any Partial Hospitalizations?______When______Where__________________________
Are you currently taking medications for depression? ___Anxiety? ___ Psychosis? ____ or ADD (ADHD) ?_____ If so, what__________________________________________
Do you use “street” drugs ___Alcohol___ Are you going to AA? _________ Have you been arrested for possession of “Street drugs?” Y N Outcome_____________________
Have you been ill and failed to get medical attention recently? ____yes ____no If yes, please explain:___________________________________________________________
Do you smoke?____yes____no If yes, how much:____________Number of years:_____
Former smoker?___yes ____no If yes, when did you quit?_______________
Please describe any changes in your appetite in the last six months:__________________
Any weight loss?___yes____no Amount of weight loss:___________ Do you sleep well?____yes ____no Have you slept less in the last six months?____yes____no Try to describe what keeps you awake:______________________________________________

Allergies
List allergies to foods, drugs, dust, chemicals, bee stings, etc. and indicate the effect:
Allergic to Reaction to Allergic to Reaction to
Medications
List medications taken in the past six months, including herbal supplements.
Illness/problem Medication taken Amount Began when? Stopped when?
Relative
Mother
Father
Brothers
Indicate any family member with emotional/mental problems
Type of disorder? Has therapy helped?
Sisters
Spouse/ live in partner
Children
Have any of your relatives had any of the following illnesses?
Type of Illness
Diabetes
Cancer
Heart disease
Stroke
Epilepsy
Hypertension
Family member Type of illness
Alcoholism
Drug addiction
Depression
Psychosis
Migraines
Other
Family member
Give any other information you feel will assist us in understanding your situation
_____________________________________
Signed
Form created 10/2005 Revised 4/2011
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Date