PSYCHIATRY. Patient Name: Date: / / Date of Birth: / / Age: Pharmacy Name: Pharmacy Phone #:

PSYCHOPHARMACOLOGY AND WORKING WITH PSYCHIATRY PROVIDERS. Juanaelena Garcia, MD Psychiatry Director Institute for Family Health

PSYCHOPHARMACOLOGY AND WORKING WITH PSYCHIATRY PROVIDERS Juanaelena Garcia, MD Psychiatry Director Institute for Family Health Learning Objectives Learn basics about the various types of medications that

PSYCHOSOMATIC INSTITUTE OF SAN ANTONIO New Patient Information

PSYCHOSOMATIC INSTITUTE OF SAN ANTONIO New Patient Information Name: Last: First: MI: Birth Date: Sex: M F Marital Status: Single Married Divorced Separated Widowed Partnered Other Preferred name: Emergency

Early Morning Waking Excessively Orderly or Perfectionistic

COLLEGE OF MEDICINE Jacksonville 580 W 8 th St T-2 6 th Fl Ste 6005 6266 Dupont Station Ct Department of Psychiatry Jacksonville, FL 32209 Jacksonville, Fl 32217 Division of Adult Psychiatry Phone 904-383-1038

Lamictal, lamotrigine Lithium, lithobid, eskalith Depakote, valproate Trileptal, oxcarbazepine Tegretol, equetro, carbamazepine Atypicals (aripiprazole, abilify, olanzapine, zyprexa, invega, risperdal,

Psychiatric Medications: Pearls and Pitfalls. The majority of medications used in patients with psychiatric diagnoses have more than one use.

Psychiatric Medications: Pearls and Pitfalls Rule #1 The majority of medications used in patients with psychiatric diagnoses have more than one use. Without access to the patient s medical record, to review

Medications Used in the Management of Disruptive Behavior Disorders

The following medication chart is provided as a brief guide to some of the medications used in the management of various behavior disorders, along with their potential benefits and possible side effects.

Serenity Psychiatry, LLC Mimi Armellino, DO Of Coastal Counseling Associates. Patient History Form

Serenity Psychiatry, LLC Mimi Armellino, DO Of Coastal Counseling Associates Patient History Form Name Date Age DOB SSN Address City State ZIP Patient s Telephone (H) (W) (Cell) Email Job Title or School

University of Florida & Shands Adult Psychiatry Outpatient Clinic Intake Form

University of Florida & Shands Adult Psychiatry Outpatient Clinic Intake Form Date Name Age Address Home phone Work phone Cell phone What issue(s) bring(s) you to the Psychiatry Clinic? What has been stressing

Psychotropic Medication Reference Chart

Psychotropic Medication Reference Chart Appendix 4.14 This chart is not an all-inclusive list of medications. If you have a question regarding the classification of a medication you may consult websites

Dallas Neurosurgical and Spine Associates, P.A Patient Health History

Dallas Neurosurgical and Spine Associates, P.A Patient Health History DOB: Date: Reason for your visit (Chief complaint): Past Medical History Please check corresponding box if you have ever had any of

MOOD DISORDERS PART II BIPOLAR AFFECTIVE DISORDER (BAD) Todd Stull, M.D. James Sorrell, M.D.

MOOD DISORDERS PART II BIPOLAR AFFECTIVE DISORDER (BAD) Todd Stull, M.D. James Sorrell, M.D. BIPOLAR AFFECTIVE DISORDER (BAD) General Assessment is challenging Input important Change in level of functioning

Medicines for Treating Depression. A Review of the Research for Adults

Medicines for Treating Depression A Review of the Research for Adults Is This Information Right for Me? Yes, if: A doctor or other health care professional has told you that you have depression. Your doctor

PATIENT HISTORY FORM

PATIENT HISTORY FORM If you are new to the office, have not been seen in over one (1) year, or are returning for a new problem, please complete this form in full. If there have been any changes since your

Psychiatric Evaluation Intake Form

Psychiatric Evaluation Intake Form 1. Patient Contact Information Patient Name Preferred Name Last First MI Address_ Best contact phone number: Email address: Primary Care Physician Tel Fax Pharmacy Phone

NEW PATIENT HISTORY QUESTIONNAIRE. Physician Initials Date PATIENT INFORMATION

NEW PATIENT HISTORY QUESTIONNAIRE Physician Initials Date PATIENT INFORMATION JHH# DOB# AGE HOME PH CELL PH DAY PH EMAIL Who is your REFERRING PHYSICIAN? (The doctor who referred you to Johns Hopkins Neurology.)

NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only)

PAGE 1 NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only) 1. What is the main problem that you are having? (If additional space is required, please use the back of this

Borland-Groover Clinic PATIENT GENERATED MEDICAL HISTORY Name: DOB: Email: Primary Care Physician: Pharmacy: Pharmacy Phone #:

PATIENT GENERATED MEDICAL HISTORY Name: DOB: Email: Primary Care Physician: Referring: Pharmacy: Pharmacy Phone #: Place Sticker Here Directions: Please circle any of the following you have personally

Medication Side Effects:

Medication Side Effects: Staying Healthy While on Psychotropic Medications Megan Maroney PharmD, BCPP Clinical Assistant Professor Ernest Mario School of Pharmacy Rutgers the State University of New Jersey

St. Luke s MS Center New Patient Questionnaire. Name: Date: Birth date: Right or Left handed? Who is your Primary Doctor?

St. Luke s MS Center New Patient Questionnaire Name: Date: Birth date: Right or Left handed? Who is your Primary Doctor? Who referred you to the MS Center? List any other doctors you see: Reason you have

EMORY CLINIC, INC. Brain Health Center 12 Executive Park Dr. Atlanta, GA 30329 404-728-6302

New Patient Packet 03/10/2015 EMORY CLINIC, INC. Brain Health Center 12 Executive Park Dr. Atlanta, GA 30329 404-728-6302 Thank you for allowing us to assist in your care. We look forward to meeting you.

PLEASE COMPLETE PRIOR TO VISIT***Place your name at the bottom of each sheet

PLEASE COMPLETE PRIOR TO VISIT***Place your name at the bottom of each sheet GASTROINTESTINAL ASSOCIATES, INC. PATIENT REGISTRATION Welcome to our practice. Please complete all sections of this registration

POINCIANA INTERNAL MEDICINE PA. Patient Name: Social Security Number: Date of Birth: / / Sex: M/F (Circle One) Married/Single/Divorced/Widow Address:

Patient Name: Social Security Number: Date of Birth: / / Sex: M/F (Circle One) Married/Single/Divorced/Widow Address: (Street) (City/State/Zip) Home Phone: ( ) E Mail Address: Would you be interested in

Emory Eye Center New Patient Questionnaire

Patient Name: Date: Current Address: Current Phone: Date of Birth: Primary Care Physician: Referring Physician: (First & Last Name) (First & Last Name) Pharmacy Name: Phone #: ( ) Please answer all questions

Why are antidepressants used to treat IBS? Some medicines can have more than one action (benefit) in treating medical problems.

The Use of Antidepressants in the Treatment of Irritable Bowel Syndrome and Other Functional GI Disorders Christine B. Dalton, PA-C Douglas A. Drossman, MD What are functional GI disorders? There are more

Overview of Mental Health Medication Trends

America s State of Mind Report is a Medco Health Solutions, Inc. analysis examining trends in the utilization of mental health related medications among the insured population. The research reviewed prescription

PLEASE PRINT LEGIBLY

Patient Information PLEASE PRINT LEGIBLY Patients Name: Date of Birth: Sex: Patients Address: City: State: Zip: Home Phone: Cell: Work: Email: SSN: Employer: Occupation: Marital Status: Employed: Full

Depression. Medicines To Help You

Medicines To Help You Depression Use this guide to help you talk to your doctor, pharmacist, or nurse about your medicines for depression. The guide lists all of the FDA-approved products now available

PATIENT INFORMATION / / OTHER CONTACT NUMERS: (CIRCLE ONE) CELL, HOME OR OTHER. ENTER NUMBER BELOW. ( ) EMPLOYER ( )

PATIENT INFORMATION PATIENT S LEGAL NAME DATE OF BIRTH AGE DATE / / / / HEIGHT AND WEIGHT SEX REASON FOR VISIT: MARITAL STATUS FT IN LBS MALE FEMALE S M D W ADDRESS CITY STATE ZIP CODE THE BEST NUMBER

General Internal Medicine Clinic New Patient Questionnaire

General Internal Medicine Clinic New Patient Questionnaire Date: Name: What would you like to be called by the doctor? Marital Status: Please list how you would like to be contacted, for test results:

Medications A detailed booklet that describes mental disorders and the medications for treating them includes a comprehensive list of medications.

A detailed booklet that describes mental disorders and the medications for treating them includes a comprehensive list of medications. 2014 Contents Introduction: Mental Health Medications...1 What are

JAMES PETROS, M.D., INC. PHONE: (408) 528-8833 FAX: (408) 528-8557

FIGHTING PAIN. TOUCHING LIVES. JAMES PETROS, M.D., INC. PHONE: (408) 528-8833 FAX: (408) 528-8557 Personal Information Emergency Contact Today s Date: Name: Patient: Realtionship: Birth Date: Age: Sex:

New Patient Intake Form

New Patient Intake Form Title: (Circle one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name Address City State Zip Code Leave Messages on: (Circle one) Home Cell Work Don t leave messages

Full name DOB Age Address Email Phone numbers (H) (W) (C) Emergency contact Phone

DEMOGRAPHIC INFORMATION Full name DOB Age Address Email Phone numbers (H) (W) (C) Emergency contact Phone CARE INFORMATION Primary care physician: Address Phone Fax Referring physician: Specialty Address

Roswell Ear, Nose, Throat, & Allergy 342 W. Sherrill Lane Suite A, Roswell, New Mexico 88201 (575)-622-2911 Fax: (575)-622-2598

Roswell Ear, Nose, Throat, & Allergy 342 W. Sherrill Lane Suite A, Roswell, New Mexico 88201 (575)-622-2911 Fax: (575)-622-2598 Patient Registration Form: (Please Print all Pertinent Information) Last

A BRIEF OVERVIEW OF PSYCHOTROPIC MEDICATION USE FOR PERSONS WITH INTELLECTUAL DISABILITIES

INTRODUCTION A BRIEF OVERVIEW OF PSYCHOTROPIC MEDICATION USE FOR PERSONS WITH INTELLECTUAL DISABILITIES Individuals with intellectual disabilities are not uncommonly prescribed psychotropic medications.

Mental Health Medications

Mental Health Medications National Institute of Mental Health U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Contents Mental Health Medications..............................................................1

SOUTH TAMPA MULTIPLE SCLEROSIS CENTER

SOUTH TAMPA MULTIPLE SCLEROSIS CENTER PATIENT/CARE GIVER QUESTIONNAIRE DEMOGRAPHIC INFORMATION Patient's Name: City: State: Zip Code: Phone: Marital Status: Spouse/Care Giver Name: Phone (H) (W) Occupation:

NEW PATIENT CONSULTATION FORM. Social Security Number - - Date of Birth Age. Home Address. Home phone Cell phone. Work phone Email address

NEW PATIENT CONSULTATION FORM Welcome to our office. Please fill out the first four pages. Date Name Social Security Number - - Date of Birth Age Home Address Home phone Cell phone Work phone Email address

Application For Admission To The Non-Surgical Spinal Decompression Program At The Spinal Decompression Center of Long Beach

Application For Admission To The Non-Surgical Spinal Decompression Program At The Spinal Decompression Center of Long Beach If you are reading this form, you have qualified for a consultation with Dr.

PATIENT HEALTH QUESTIONNAIRE Radiation Oncology (Patient Label)

REVIEWED DATE / INITIALS SAFETY: Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? ALLERGIES: Do you have any allergies to medications? If, please

Arizona Department of Health Services/ Division of Behavioral Health Services Behavioral Health Drug List Effective 1/1/2014

Arizona Department of Health Services/ Division of Behavioral Health Services Behavioral Health Drug List Effective 1/1/2014 The Arizona Department of Health Services, Division of Behavioral Health Services,

Medications for Huntington s Disease Vicki Wheelock, M.D.

Medications for Huntington s Disease Vicki Wheelock, M.D. Director, HDSA Center of Excellence at UC Davis June 4, 2013 Outline Introduction and disclaimers Medications for cognitive symptoms Medications

Recognition and Treatment of Depression in Parkinson s Disease

Recognition and Treatment of Depression in Parkinson s Disease Web Ross VA Pacific Islands Health Care System What is depression? Depression is a serious medical condition that affects a person s feelings,

Pulmonary Associates of Richmond

Pulmonary Associates of Richmond Name: Address One: City: Home Phone#: Work Phone#: Cell Phone#: State: Zip: Sex: Social Security Number: Referring Doctor: of Birth: Employer: Primary Care Doctor: Employment

PATIENT DEMOGRAPHICS & INSURANCE INFORMATION

PATIENT DEMOGRAPHICS & INSURANCE INFORMATION State: Zip Code: Preferred Pharmacy: Phone: Home Work Other Referring Physician: Phone: Home Work Other Primary Care Physician: E-Mail Address: EMERGENCY CONTACT

Bipolar Disorder. Mania is the word that describes the activated phase of bipolar disorder. The symptoms of mania may include:

Bipolar Disorder What is bipolar disorder? Bipolar disorder, or manic depression, is a medical illness that causes extreme shifts in mood, energy, and functioning. These changes may be subtle or dramatic

Psychotropic Medication

Page 1 T I P S F O R P R A C T I C E Psychotropic Medication Psychotropic medications are symptomatic medications that affect attention, emotions, or behaviors. Communication between the physician, NDHHS

Southwest General Surgical Associates General & Vascular Surgery 8230 Walnut Hill Lane Suite 408 Dallas, TX 75231 Phone-214)369-5432 Fax-214)369-5591

Southwest General Surgical Associates General & Vascular Surgery 8230 Walnut Hill Lane Suite 408 Dallas, TX 75231 Phone-214)369-5432 Fax-214)369-5591 Andres U. Katz, M.D. Richard S. Anderson, M.D. G. Thomas

ORTHOPAEDIC SPINE PAIN QUESTIONNAIRE

ORTHOPAEDIC SPINE PAIN QUESTIONNAIRE NAME: DATE: ADDRESS: AGE: TELEPHONE#: RELIGION: OCCUPATION: REFERRED BY WHOM: NEAREST FRIEND/RELATIVE: TELEPHONE#: ADDRESS: PLEASE EXPLAIN WHY YOU HAVE COME TO SEE

SECTION M BEHAVIORAL HEALTH SERVICES

Phoenix Health Plan s (PHP) goal for its members is to ensure that behavioral health services are readily available for Title XIX (Medicaid) and the Title XXI (KidsCare) members. Comprehensive behavioral

NEW YORK SPINE & PAIN PHYSICIANS NEW PATIENT QUESTIONNAIRE

NEW YORK SPINE & PAIN PHYSICIANS NEW PATIENT QUESTIONNAIRE DEMOGRAPHICS- To be completed by all patients Patient Name: Today s Date: / / Patient Address: _ City: State: Zip: Home Phone #: ( ) - Work #:

Oral Fluid Drug Testing March 23 rd, 2015

Oral Fluid Drug Testing March 23 rd, 2015 Drug Testing Options Breath Blood Meconium Vitreous Hair Sweat Urine Oral Drug Testing Options Oral Fluid and Blood and Breath Actual levels (immediate use, up

PELED PLASTIC SURGERY HEADACHE HISTORY FORM

HEADACHE HISTORY FORM IF THIS IS YOUR FIRST VISIT, PLEASE TAKE THE TIME TO FILL THIS FORM OUT COMPLETELY. Patient Name: Age: Date of Birth: Weight: Height: Address: City: State: Zip: Home Phone: Cell Phone:

North Carolina Orthopaedic Clinic Patient Registration Form

North Carolina Orthopaedic Clinic Patient Registration Form FOR US TO PROCESS YOUR CHART, PLEASE COMPLETE FULLY AND PRINT CLEARLY PATIENT INFORMATION NAME: BIRTHDATE: AGE: TODAY S DATE: SOCIAL SECURITY

ANTIDEPRESSANT MEDICINES. A GUIDE for ADULTS With DEPRESSION

ANTIDEPRESSANT MEDICINES A GUIDE for ADULTS With DEPRESSION August 2007 FAST FACTS ON ANTIDEPRESSANTS The antidepressants in this guide work for treating depression. Most people can find one that makes

Denver Spine Surgeons David Wong, MD, Sanjay Jatana, MD, Gary Ghiselli, MD

Cervical and Lumbar Spine Health History Name: Today s Date: Referring Provider: How did you find us: (Please circle) Primary care physician, Google search, Facebook, Friend or Family member, Website (JatanaSpine

Handout 2 List of medications used to treat mental illness

Navigating Boundaries: Setting Sail With A Mentally Ill Client Handout 2 List of medications used to treat mental illness Information synthesized from www.drugs.com. Additional Information: CR following

BIPOLAR DISORDER A GUIDE FOR INDIVIDUALS AND FAMILIES FOR THE TREATMENT OF BIPOLAR DISORDER IN ADULTS

BIPOLAR DISORDER A GUIDE FOR INDIVIDUALS AND FAMILIES FOR THE TREATMENT OF BIPOLAR DISORDER IN ADULTS A publication of the Massachusetts Department of Mental Health and the Massachusetts Division of Medical

Plano Heart Center, P.A.

Plano Heart Center, P.A. Date: How did you hear about us: Physician Referral Advertisement Friend Other. Please specify: Patient Information Name: Social Security #: Address: City: State: Zip: Home Ph:

Southwestern Foot & Ankle Associates, P.C. 3880 Parkwood Blvd, Suite 602 Frisco, TX 75034 Phone: 972-335-9071 Fax: 972-335-8920 Dr. Thomas H.

Phone: 972-335-9071 Fax: 972-335-8920 Date: Home Phone ( ) Patient Information (Please Print) Email: Name: SS/Patient ID # Last Name First Name Middle Initial Address Cell Phone ( ) City State Zip Sex

NEUROSURGERY SERVICES AT APD LOCATED AT UPPER VALLEY MEDICAL GROUP 106 Hanover Street, Lebanon, NH 03766 Phone: 603.448.0447 Fax: 603.448.

DATE NEUROSURGERY SERVICES AT APD LOCATED AT UPPER VALLEY MEDICAL GROUP 106 Hanover Street, Lebanon, NH 03766 Phone: 603.448.0447 Fax: 603.448.0019 Joseph M. Phillips, M.D., Ph.D. Board Certified in Pain

1MFBTF GJMM PVU GPSNT BOE GBY 'PSNT XJMM CF TJHOFE BU ZPVS BQQPJOUNFOU

CELL PHONE: PATIENT HISTORY FORM - CONFIDENTIAL DATE: PATIENT: (LAST NAME) (FIRST NAME) (Ml) (NICKNAME) DOB: Primary Physician/ Family Doctor: Phone: Past Medical History (Click all that apply) High blood

Name: Date of Birth: Age: Male / Female (circle one) Pregnant Yes / No (circle one) Reason you are here:

Eastside Medical Group: DATE: Name: Date of Birth: _Age: Male / Female (circle one) Pregnant Yes / No (circle one) Reason you are here: SOCIAL HISTORY Marital Status: Single Married Partner Divorced Widow/Widower

Antipsychotics and the Nursing Home

Antipsychotics and the Nursing Home Lisa M. O Hara, PharmD, CGP Corporate Director of Clinical Services The State Operations Manual Part 1: F329 Unnecessary Drugs Medication Management Defined Helps promote

Pharmacotherapy of BPSD. Pharmacological interventions. Anti-dementia drugs. Abhilash K. Desai MD Medical Director Alzheimer s Center of Excellence

Pharmacotherapy of BPSD Abhilash K. Desai MD Medical Director Alzheimer s Center of Excellence Pharmacological interventions Reducing medication errors. Reducing potentially inappropriate medication prescription.

412 Holistic Health, LLC Maura Schuster, L.OM 412.841.2065 Practitioner of Oriental Medicine NEW PATIENT INTAKE

412 Holistic Health, LLC Maura Schuster, L.OM 412.841.2065 Practitioner of Oriental Medicine NEW PATIENT INTAKE PATIENT INFORMATION Date Name Address City State Zip Age Birthdate Occupation Company name

Memorial Hospital Sleep Center. Rock Springs, Wyoming 82901. Sleep lab Phone: 307-352- 8229 (Mon - Wed 5:00 pm 7:00 am)

Memorial Hospital Sleep Center Rock Springs, Wyoming 82901 Sleep lab Phone: 307-352- 8229 (Mon - Wed 5:00 pm 7:00 am) Office Phone: 307-352- 8390 (Mon Fri 8:00 am 4:00 pm ) Patient Name: Sex Age Date Occupation:

The NeuroCenter Swedish Covenant Medical Group 6225 W. Touhy Ave, Chicago, Il 60646 Tel: 773-775-7540 Fax: 773-763-9792

The NeuroCenter Swedish Covenant Medical Group 6225 W. Touhy Ave, Chicago, Il 60646 Tel: 773-775-7540 Fax: 773-763-9792 1 PAIN MANAGEMENT SERVICES New Patient Questionnaire Date: Primary MD: Referring

BREAST HEALTH HISTORY FORM

BREAST HEALTH HISTORY FORM Name Date of Visit: Date of Birth: Age: REFERRING PHYSICIANS: please include name, address and phone number of all physicians whom you would like to receive report of today s

NEW PATIENT CLINICAL INFORMATION FORM. Booth Gardner Parkinson s Care & Movement Disorders Center Evergreen Neuroscience Institute

NEW PATIENT CLINICAL INFORMATION FORM Booth Gardner Parkinson s Care & Movement Disorders Center Evergreen Neuroscience Institute Date: Name: Referring Doctor: How did you hear about us? NWPF Your Physician:

Welcome to Who Wants to be an APNA Millionaire!

Welcome to Who Wants to be an APNA Millionaire! Drug-Drinks Interactions Drug-Drug Interactions Mary Gutierrez, PharmD, BCPP Clinical Professor of Pharmacy Practice (Psychiatry) Chapman University, School

NEW PATIENT INFORMATION FORM

Woosik M. Chung, M.D. Timothy R. Kuklo, M.D., J.D. 303-762-DISC (3472) NEW PATIENT INFORMATION FORM Please print all information. By fully completing this form, you allow us to serve you quickly and efficiently.

CLINIC APPLICATION. Client Information

ICNA Relief USA Shifa Free Medical Clinic 1092 Johnnie Dodds Boulevard, Suite 108 Mount Pleasant, SC 29464 Tel: (843) 352-4580 Fax: (843) 375-9063 Last Name Street Address City, State, Zip Code Home Phone

PATIENT SELF-ASSESSMENT FORM

PATIENT SELF-ASSESSMENT FORM Please complete the information below to the best of your ability. Personal Information Name: Address: City: State: Zip: Telephone: Email: Name of referring physician: Address:

Behavioral Health Diagnoses, Symptoms, and Interventions for Children Ages 4 and older

Diagnosis Typical symptoms Behavioral interventions known to work (Evidence-informed; Manualized) *Descriptions provided below Trauma-related disorders Post-traumatic stress disorder --------------------------

MEDICATIONS AND TOURETTE S DISORDER: COMBINED PHARMACOTHERAPY AND DRUG INTERACTIONS. Barbara Coffey, M.D., Cheston Berlin, M.D., Alan Naarden, M.D.

MEDICATIONS AND TOURETTE S DISORDER: COMBINED PHARMACOTHERAPY AND DRUG INTERACTIONS Barbara Coffey, M.D., Cheston Berlin, M.D., Alan Naarden, M.D. Introduction Tourette Syndrome (TS) or Tourette s Disorder

Clinical Practice Guideline: Depression in Primary Care, Adult 4 Taft Court Rockville, MD 20850 www.mamsi.com

Clinical Practice Guideline: Depression in 4 Taft Court Rockville, MD 20850 www.mamsi.com 40 05 17 035 3/03 Once a primary care patient presents with depressive symptoms, the primary care physician makes

INITIAL PATIENT QUESTIONNAIRE-

Date: Patient Address: Home Phone: Work Phone: Age: Height: cm/inches Weight: kg/lbs Male Female Referring Physician s Name: Physician Phone: Physician Address: Type of Practice (Internist, Surgeon, etc.):

OMNI DERMATOLOGY, INC. NEW PATIENT INFORMATION RECORD

OMNI DERMATOLOGY, INC. NEW PATIENT INFORMATION RECORD Name Last: First: MI: Social Security Number: Date of birth: / / Sex: M F Address: Street City State: Zip Code: Contact Numbers: Home Phone: ( ) -

MOTOR VEHICLE ACCIDENT QUESTIONNAIRE

MOTOR VEHICLE ACCIDENT QUESTIONNAIRE Thank you in advance for taking the time to complete this form, this will help us to better assess all of your pain concerns and provide you with the best treatment.

PREMIER PAIN CARE PA Carlos J Garcia MD 2435 W. Oak Street # 103 Denton, TX 76201 Phone 940-323-9404 Fax 940-323-9422 PATIENT REGISTRATION

PREMIER PAIN CARE PA Carlos J Garcia MD 2435 W. Oak Street # 103 Denton, TX 76201 Phone 940-323-9404 Fax 940-323-9422 PATIENT REGISTRATION Last Name First Name MI Mailing Address City Zip code Home Phone

POPULAR DEPRESSION MEDICATIONS

Popular Depression Medications A Helpful Guide to Antidepressant Drugs POPULAR DEPRESSION MEDICATIONS A Helpful Guide to Antidepressant Drugs Popular Depression Medications A Helpful Guide to Antidepressant

Patient Registration Form

PATIENT INFORMATION Patient Registration Form (Please Print) Dr. Miss Mr. Mrs. Ms. Sir Jr. Sr. Patient s Name (Last) (First) (MI) Previous Name Mailing Address City, State, ZIP (+4) Physical Address City,

MEDICAL HISTORY AND SCREENING FORM

MEDICAL HISTORY AND SCREENING FORM The purpose of preventive exams is to screen for potential health problems and provide education to promote optimal health. It is best practice for chronic health problems

SLEEP DISORDER ADULT QUESTIONNAIRE

SLEEP DISORDER ADULT QUESTIONNAIRE Name: Date: Date of Birth (month/day/year): / / Gender: ο Male ο Female Marital Status: ο Never Married ο Married ο Divorced ο Widowed Home Address: City: Zip: Daytime

PATIENT DEMOGRAPHICS:

PATIENT DEMOGRAPHICS: Last Name: First: MI: Address: City: State: Zip: Please check off the phone numbers you would like us to call regarding appointment conformations. Home: Cell: May we leave a message?

How to Remove a Social History Smoke?

AUSTIN RETINA ASSOCIATES PATIENT INFORMATION NAME: MAILING ADDRESS or NURSING HOME NAME & ADDRESS: Last First Middle Initial CITY: STATE: ZIP CODE: - TELEPHONE: HOME:( ) CELL: ( ) WORK:( ) DATE OF BIRTH:

PATIENT INTAKE / HISTORY FORM PATIENT INFORMATION

Mona Mikael, Psy.D., PSY 25089 Neuro- Rehabilitation Psychologist Neuro- Rehab Psychological Consultation & Treatment 630 S. Raymond Ave., #340 Pasadena, CA 91105 626-710- 7838 Web: www.neurorehabtlc.com

Interventional Spine Pain Consultants, P.A. Initial Consultation Information

Interventional Spine Pain Consultants, P.A. Initial Consultation Information Date: / / Date of Birth / / Age: Name: Name of the provider that recommended you to our office? Name of your primary care doctor?

remeron user reviews remeron medicine remeron suicide

Overdose symptoms may occur using therapeutic dosages, antidepressants remeron the risk of side effects to FDA at 1-800-FDA-1088. The most common lorazepam side effects. This material is provided for educational

Surgical weight loss. Life-changing results.

Surgical weight loss. Life-changing results. Our surgical weight loss team is devoted to helping patients overcome obesity and reclaim the life, health and future you deserve. Minimally invasive weight

Personal Injury Questionnaire

Personal Injury Questionnaire Patient Information Date Date of Birth Health Insurance Do you have a Flex Spending (FSA) or Health Savings (HSA) Account? Y N Patient Name First M Last What do you prefer