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Background info
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Past medical history
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1. Allergies:
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2. Primary Care Provider and phone number:
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3. Other medical specialists you see:
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4. Weight
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5. Height:
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6. Current non-psychiatric medications you take (name, dose, reason for taking):
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7. Current over the counter or vitamins/supplements you take:
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8. Current medical problems
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9. Past medical problems, surgeries, and non-psychiatric hospitalizations:
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10. Have you ever had an EKG?
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11. If yes, was the EKG
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12. Have you had any recent labs or blood work completed? If yes, when? Did they show any abnormalities?
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13. When was your last physical exam?
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14. For women only: any chance you may be pregnant?
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15. Method of birth control, if any:
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16. Personal and family medical history: Please check if you or a family member have experienced any of the below conditions:
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17. When your mother was pregnant with you, do you if there were any complications with the pregnancy or birth? If so, please de
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18. How are your relationships with your family members?
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19. Have there been any problems with your family in the past or currently such as abuse, conflicts, stress, or loss?
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20. How are your relationships with your extended support circles, such as friends, colleagues, classmates, neighbors, etc.?
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21. What is your current relationship status?
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22. With whom do you currently live?
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23.What is the highest level of education you completed?
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24. Would you describe your schooling experience as positive overall?
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25. Are you currently in school or a training program?
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26. What do you do for work? Are you employed part time or full time? How many hours per week?
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27. Have you served in the military?
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28. Is there anything else you would like to share?
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29. If you are currently having any thoughts of self-harm or suicide, it is important that you seek immediate crisis interventio
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Test link
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