First Name:
Last Name:
Email:
Phone:
Cell / Alternate Phone:
Age: Height:
Weight: Emergency Contact:
Address: Primary Drug of Addiction:
Brief history of your addiction or condition you are seeking treatment for.
BriefList of Medications: Include daily dosages: List of all non-prescribed medications / or street drugs used in the past 30 days.
List of all non-prescribed medications / or street drugs used in the past 30 days. List of medications prescribed, but, not taking:
List of all supplements / performance enhancers currently taking / or have taken in past month.:
List of all foods / medications you are allergic to.: List any major surgeries you have had, including approximate date.: Do you drink alcohol?: YESNO if yes, how much and how often?:
Do you smoke?: YESNO If yes, how much per day?
Do you have a history of myocardial infarction or heart disease? If so, explain.
Do you have hypertension or hypotension?: YESNO
Do you have a history of seizures?: YESNO Do you have a history of vascular disease, including aneurysms? If so, how is it being treated?:
Do you have a history of embolism, problems w/ blood clotting or recent trauma, including the pelvis or legs? If so, please explain?: Do you have diabetes?: YESNO If yes, are you insulin dependent?: YESNO Do you have fainting spells or get dizzy upon getting up suddenly? If so, please explain.: Do you have a history of ulcerate colitis, Cronin's Disease, bleeding or peptic ulcers? If yes, please explain.: Do you have any type of hepatitis, including abnormal liver function tests, hepatitis C, primary biliary cirrhosis, elevated serum ammonina levels, etc . . .? If yes, please explain.: Do you consider yourself to be depressed? If yes, please explain.: Have you ever tried to commit suicide? If yes, please explain.: Have you ever been admitted to a psychiatric hospital? If yes, please list approximate dates and condition you were treated for.:
Do you have any type of brain damage, including traumatic or closed head injuries w/ or w/o unconsciousness or seizures? If yes, please explain.: Are you asthmatic? If yes, do you use an inhaler?: Do you suffer from or have any of the following physical conditions? Check all that apply. Diabetes: YESNO Hepatitis A, B or C: YESNO History of Ulcers: YESNO Slow Heart Rate: YESNO Jaundice: YESNO
Thyroid Problems: YESNO
Heart Disease: YESNO Respiratory Problems: YESNO Loss of Menstruation: YESNO
Excessive Menstruation: YESNO
Joint Pain: YESNO
Varicose Veins: YESNO
Back Problems: YESNO Nausea:
YESNO Dizzy: YESNO
High Blood Pressure: YESNO
Kidney Problems: YESNO
Renal Disease: YESNO
Nerve Damage: YESNO
Constipation: YESNO
Stroke: YESNO Bleeding: YESNO Stomach Problems: YESNO Liver Problems: YESNO History of Seizures: YESNO Urinary Problems:YESNO Heart Problems:YESNO Low Blood Pressure:YESNO Asthma :YESNO Painful Menstruation:YESNO
Cancer:YESNO Fainting :YESNO Numbness :YESNO Diarrhea :YESNO HIV Positive / Aids Shaking:YESNO Tuberculosis:YESNO Shortness of Breath :YESNO Muscle Spasms :YESNO Heartburn:YESNO Obesity:YESNO
Additional Comments: If you have an EKG, Lab Test or Medical records please attach here ACCEPTED When you are ready and you have finished filling in all the required fields, select ACCEPTED and then the SUBMIT button. Check that you do not receive an error message to ensure that the information has been sent properly.
