Medical Questionnaire

What is the major problem for which you are seeking help at this time?

When did this problem begin?

Have you ever had this problem before in your life? If so, when:

Have you been treated for the above problem or any mental health issues before:

Yes

Please list all psychiatric medications you have ever taken including antidepressants, mood stabilizers, antipsychotics, tranquilizers, sleeping pills, antiseizure medications and Vitamins HerbalNon Prescription Remedies:

Alcohol Use per week: (beer [12 oz], liquor, wine, other)

Tobacco use

Yes

Caffeinated drinks per day:

Select the substances that you have used:

Alcohol

Inhalants

PCP

Caffeine pills

LCD or hallucinogens

Stimulants (pills)

Cocaine

Marijuana

Tranquilizers/Sleeping pills

Crystal meth/amphetamines

Methadone

Ecstasy

Heroin

Pain meds

None of the above

Other:

Did you ever stop using any of the substances of the above because of dependance? (please list)

What was your longest period of abstinence? (If you would prefer to discuss this issue in person, please indicate below)

List all Previous psychiatric hospitalizations: (include hospital name, location, date of admission, reason of admission, doctors name)

List the dates of any DUI’s, traffic accidents or legal problems currently or in the past: (If you would prefer to discuss this issue in person, please indicate below)

List all the medical conditions for which you are being treated:

List any medication allergies:

Current medications:

Have you had any surgeries or been hospitalized? (please explain)

Family history of medical or psychiatric illness:

Are you currently employed? If so, what type of work do you do?

Have you ever had a work related injury or been on Worker’s Compensation? If so, for what and when:

Are you on Social Security Disability? If so when did it begin and for what reason?

Highest Level of Education:

Were you ever in the military? If so, when, what division and type of discharge?

Name

Date of birth

Signature

ADDRESS

4229 Lafayette Center Drive
Suite 1760
Chantilly Virginia 20151.

CONTACTS

Email: support@PAofNova.com
Phone: +1 (571)306-7919
Fax: +1 (571)306-7802

OFFICE HOURS

Mon-Fri 9:00 AM to 6:00 PM
Saturday & Sunday - Closed
For emergencies call 911

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