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Review of Medical History
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How did you find out about us?
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Do you currently have a primary physician?
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Primary Care Physician Name
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City Physician is Located
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Risk Factors
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Cardiovascular Disease
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Liver Disease
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Episodes of Psychosis
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Arrhythmia
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Kidney Disease
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Social History
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Do you have a history of substance use disorder?
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If Yes, please describe
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Is there a Family history of substance use disorder?
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If Yes, please describe
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Mental Health
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Do you have a mental health disorder?
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If yes, please describe
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Is there a Family history of mental health disorders?
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If yes, please describe
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Vitals
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What is your height?
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What is your approximate weight?
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Pregnancy/Breastfeeding
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If Female (Check Box)
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Currently Breastfeeding
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Currently Pregnant
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Planning to become pregnant
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