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INTAKE FORM-----Bernard Member, MD

 

DATE__________________

LAST NAME______________________   FIRST NAME______________________

DATE of BIRTH____________________   AGE___________

ADDRESS__________________________________________________________

PHONE           HOME_______________________  CELL_______________________

EMAIL_____________________________________________________________

CONTACT PERSON/PHONE ____________________________________________

PHARMACY (name & address)__________________________________________

INSURANCE (Name, ID, Phone)_________________________________________

                                                        _________________________________________

REFERRED BY____________________

ACCOUNT GUARANTOR (If patient, just write "self"):

Name, Address, Phone, Relationship         ___________________________________________________________________

___________________________________________________________________

 

                                       

                                                    POLICIES

If you cancel your appointment without 1 day notice, the charge is $50.

The returned check fee is $35.

Please notify the office of address, phone or insurance changes.

                                        

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                                       MEDICAL INFORMATION

SERIOUS MEDICAL (not Psychiatric) PROBLEMS:                                                             

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CURRENT PSYCHIATRIC MEDICATIONS/DOSES:

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PAST & CURRENT DRUG or ALCOHOL USE:

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FAMILY HISTORY of MENTAL ILLNESS:

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PREVIOUS PSYCHIATRIC HOSPITALIZATIONS:

___________________________________________________________________
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PAST PSYCHIATRIC DIAGNOSES:

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CURRENT SYMPTOMS & REASON FOR THIS APPOINTMENT:

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