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Psychiatric History Information Sheet

If you prefer, you can print this form, fill it out and deliver it to the office.

Only complete if seeing Psychiatry
Please complete all fields. If there is no answer or the question doesn't apply to you, please enter "None" or "N/A".

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Have you ever seen a psychiatrist?

Have you ever taken psychiatric medications before? (including medications for depression, anxiety, sleep, memory/focus, mood)

List as many medications as you can remember (if any)
Click on the '+' sign to add more medications
Medication/Length of time taken
Did it help?
Side effects (if any)
 
Have you ever attempted suicide?
Cancer
Diabetes
Heart Disease
Hypertension
Depression
Anxiety
Bipolar
Dementia
Schizophrenia
Substance Abuse
Parkinson's
Epilepsy/seizures
Multiple Sclerosis

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