Medical Insurance Information

If you have experienced any of these symptoms in the past or if you are currently experiencing them, please select current, past (or both) on the table below:
Current / Past
Current / Past
Current / Past
Current / Past
 Type of Outpatient TreatmentDatesClinician / DoctorFrequency of Visit
1.-
2.-
3.-
 Psychiatric Hospital NameReason for HospitalizationDates
1.-
2.-
3.-
Family history of psychiatric illness:(relationship / illness)
Social History
Substance Use History:
SubstanceAge at 1st UseFrequencyAmount UsedLast UsedProblems (physical, legal, occupational, relationships, etc.)
ALCOHOL
TOBACCO
MARIJUANA
COCAINE
AMPHETAMINES
ECSTACY
LSD/ACID
OPIATES
INHALANTS
HALLUCINOGENS
Legal Problems:
Medical History:
Medication / DoseBeneficial EffectsSide EffectsDurationReason StoppedDosage
Example: Abilify -20 mg at bedtimeHelpedHeadaches7/03 - PresentDidn’t work2.5 ml
Abilify (aripiprazole)
Atarax (hydroxyzine)
BuSpar (buspirone)
Benadryl (diphenhydramine)
Celexa (citalopram)
Cogentin (benztropine)
Cymbalta (Duloxetine)
Desyrel (trazodone)
Effexor / Effexor XR (venlafaxine)
Geodon (ziprasidone)
Haldol (haloperidol)
Invega (paliperidone)
Klonopin (clonazepam)
Lamictal (lamotrigine)
Lexapro (escitalopram)
Librium (benzodiazepine)
Lithobid, Lithonate, Lithotabs (lithium)
Luvox / Luvox CR (fluvoxamine)
Metadate ER / Metadate CD (methylphenidate)
Paxil / Paxil CR (paroxetine)
Pristiq (desvenlafaxine)
Prozac (fluoxetine) / Prozac weekly
Remeron / Remeron Soltab (mirtazapine)
Risperdal (risperidone)
Sapharis (asenapine)
Sarafem (fluoxetine)
Seroquel / Seroquel XR (quetiapine)
Serzone (nefazodone)
Symbyax (thienobenzodiazepine)
Tegretol (carbamazepine)
Topamax (topiramate)
Trileptal (dibenzazepine)
Valium (diazepam)
Wellbutrin SR / Wellbutrin XL (bupropion)
Xanax / Xanax XR (alprazolam)
Zoloft (sertraline)
Zyprexa / Zyprexa Zydis / Zyprexa IM
Others: