Form- Patient History

Name *

First

Last

Age *

Date of Birth (mm/dd/yyyy) *

Email *

Phone Number *

Street Address *

City *

State *

ZIP/Postal Code *

Country *

What kind of practitioner is currently caring for you? *

Practitioner's Name *

Practitioner's Phone *

What Medications are you taking? *

Have you ever attempted suicide? *

Yes
No

Are you currently suicidal? *

Yes
No

What medical conditions do you have or have had in the past? (check all that apply) *

If you checked any of the boxes, please provide details on your condition(s) *

Are You Pregnant?

Yes
No
Not Sure

Are You Breastfeeding?

Yes
No

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If you are allergic to any medications, please list them here:

Have you or anyone in your family had an adverse reaction to anesthesia?

Yes
No
Not Sure

If you answered yes, please describe the adverse reactions to anesthesia:

Do you drink more than 2 drinks a day?

Yes
No

Do you use any recreational drugs?

Yes
No

If you answered yes above, please list type of drug and date of last use:

Have you ever been treated for substance abuse?

No
Yes- drugs
Yes- alcohol
Yes- both

Patient Attestation: By submitting this form, I certify that I have completed this Patient Form to the best of my ability. I agree to seek immediate help should my symptoms worsen or I experience an increase in suicidal thoughts, feelings or urges. I authorize a representative from the Vitality Medical Infusions to contact me to discuss treatment options for my condition(s). I also understand that the staff of Vitality Medical Infusions will not start and maintain any prescribed treatment regimen if I am not currently under the care of a Mental Health Professional and maintain such care until the completion of my course of treatment. *

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PATIENT HISTORY