History and Physical

Personal Information

Full name	Enter full name
Birthday (MM/DD/YYYY)	Enter birthday (MM/DD/YYYY)
Home address	Enter home address
Home phone	Enter home phone
Mobile or cellular phone	Enter mobile or cellular phone
Home fax	Enter home fax
Home email address	Enter home email address
SSN	Enter ssn
Payment Card	Enter Credit Card type
Driver’s license number	Enter driver’s license number

Payment information

Credit card type	Issuing bank	Credit card no.	Phone number
Enter credit card type 1	Enter issuing bank	Credit card no.	Enter phone number
Enter credit card type 2	Enter issuing bank	Credit card no.	Enter phone number
Enter credit card type 3	Enter issuing bank	Credit card no.	Enter phone number

Insurance Provider

Company	Enter company
Business address	Enter business address
ID	Enter ID number
Insurance Phone	Enter business phone
Business fax	Enter business fax
Business email address	Enter business email address

Emergency and Medical Information

In case of emergency, contact	Enter in case of emergency, contact
Emergency contact’s address	Enter emergency contact’s address
Emergency contact’s phone	Enter emergency contact’s phone
Doctor’s name	Enter doctor’s name
Doctor’s phone	Enter doctor’s phone
Diagnoses:	Enter each current mental health diagnosis
Medical insurance carrier and member number	Enter medical insurance carrier and member number
Blood type	Enter blood type
Known medical conditions	Known medical conditions
Known allergies	Enter known allergies
Current medications Past Medications	Enter all current medications Enter all past psychiatric medicatiosn

Pharmacy

Enter drug store	address	city	state

Health History

Diagnosis	When, where diagnoses
Diagnosis	Enter company
Diagnosis	Enter company phone number
Diagnosis	Enter confirmation number
Diagnosis	Enter quoted rental rate
Surgery history:	Enter pick-up location
Medical Illness:	Enter drop-off location
Chance of pregnancy	Birth control

Family History of Psychiatric, mental, behavioral, substance use disorders:

Relation/Mental Illness:

Hospitalization or rehabilitation for mental health or substance use

Date	Hospital	City, Country	Length of stay	reason
Enter date	Hospital	Enter City, Country	Length of stay	reason
Enter date	Hospital	Enter City, Country	Length of stay	reason
Enter date	Hospital	Enter City, Country	Length of stay	reason
Enter date	Rehab	Enter City, Country	Length of stay	reason
Enter date	rehab	Enter City, Country	Length of stay	reason

Substance use History

Drug/substance	Onset of use	frequency/amount	Last use

Length of longest sobriety/when

Social

Lives with	Enter relationship status
Highest level of education
Employment	Enter if Full /part time	Unemployed/disability
Legal issues past/present