MAT New Patient Medical History


Name: Date of Birth:  

Do you have a primary care provider?

 

If yes, where/who:  

Approximate date of last visit:  

Other providers and specialties involved in your care (include medical providers and counselors):

 

Current and past medical conditions (check all that apply):

Lung disease:

 

Heart disease:

 

Neurologic (brain and nerve) disease:

 

Stomach or bowel disease:

 

Kidney or urinary disease:

 

Autoimmune disease:

 

Chronic pain conditions:

 

Diabetes:

 

High blood pressure:

 

High cholesterol:

 

Cancer:

 

COVID infection:

 

Serious accidents:

 

Mental health diagnoses:

 

Please note any hospitalizations (medical and psychiatric):

 

Please note any surgeries you have had:

 

Please list any current medications:

 

Allergies to medications:

 

Method of birth control, if applicable:  

Last menstrual period, if applicable:  

Planning pregnancy?

 

Do you own or have access to firearms or other weapons?

 

 

Family medical and psychiatric history (check all that apply):

Lung disease:

 

Heart disease:

 

Kidney disease:

 

Neurologic disease:

 

Stomach or bowel disease:

 

Autoimmune disease:

 

Diabetes:

 

High blood pressure:

 

High cholesterol:

 

Cancer:

 

Mental health conditions:

 

Leave this empty:

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Document name: MAT New Patient Medical History
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June 8, 2023 10:07 am PDTMAT New Patient Medical History Uploaded by Do Not Reply - donotreply@c-f-d.org IP 192.111.94.3
June 8, 2023 11:47 am PDTMM Records - mmrecords@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 192.111.94.3
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