Patient Health History

By completing the following health history survey the doctor will have the necessary information to proceed with diagnostics/treatment. Please complete all fields to the best of your knowledge.

HEALTH HISTORY


Leaving areas with “Select One” as your answer will invalidate your submission


Patient Information




 





 


enter 'none' if none


enter 'none' if none

 
Birth and Development






Patient Illnesses









Explain "Yes" response above

Patient Mental Disorders

None

Anxiety

Bipolar

OCD

Depression

Eating

Impulse Control

Mood

ODD

Personality

Psychotic

Other

 

For items below include reason, dates and duration



please describe or none


please describe or none


please describe or none


Family History






 
Family Mental Disorders

None

Anxiety

Bipolar

OCD

Depression

Eating

Impulse Control

Mood

ODD

Personality

Psychotic

Other

 
Patient Social History





Describe: beer, wine, hard alcohol including volume per day usage.


Describe: cigarettes, cigars, snuff, chew, quantity per day usage and dates.


Drug Use "Previous" History
None
Amphetamine
Cocaine
Heroin
LSD
Marijuana
MDMA
Methamphetamine
Opium
PCP
Other Not Listed
Rehab Center - Yes
 
Drug Use "Current" History

None
Amphetamine
Cocaine
Heroin
LSD
Marijuana

MDMA
Methamphetamine
Opium
PCP
Other Not Listed
Rehab Center - Yes



Have you had previous ADHD Treatment "Not Current"


If "Yes" above complete the following information.



 
Meds Taken
None
Adderall
Adderall XR
Adhansia
Aptesio
Concerta
Contempla
Evekeo
ER
Focalin
Intuniv
Metadate CD
Methylphenidate
Quillichew
Quillivant
Ritilin
Vyvanse
XR-ODT
Zenzedi


Reason for stopping meds. Side Effects
Ineffective
Didn't Need
Cost
Other


 

 
Previous Treating Physician




 
Are You Currently Being Treated for ADHD?

If "Yes" above complete the following information.

(details otherwise none)

(details otherwise none)

Meds Taken
None
Adderall
Adderall XR
Adhansia
Aptesio
Concerta
Contempla
Evekeo
ER
Focalin
Intuniv
Metadate CD
Methylphenidate
Quillichew
Quillivant
Ritilin
Vyvanse
XR-ODT
Zenzedi



Reason for stopping meds. Side Effects
Ineffective
Didn't Need
Cost
Other

 


 
Current Treating Physician