Past Psychiatric History

Please list any other person who has been providing or has provided mental health care for you and when you were under their care. This may be another psychiatrist, a psychologist, social worker, school counselor, individual therapist, marital therapist, minister, priest or pastoral counselor. You should include anyone who has prescribed psychiatric medication for you (primary care provider, OBGYN, family nurse practitioner, other health care provider.

List all current medications, dosage, instructions, who prescribes them and what you take them for:

Alcohol and Drug History

I have tried to cut back on my drinking.

I have become angered or annoyed by others criticizing my drinking.

I feel guilty about my drinking.

I have gotten up in the morning and had a drink to steady my nerves.

Alcohol

Marijuana

Cocaine

Crystal Meth

Ice

Adderall

Vyvanse

Ritalin

LSD

XTC/Molly

Peyote

Ketamine

Mushrooms

Xanax

Valium

Klonopin

Ativan

Dextromethorphan

Steroids

Spice

Bath Salts

Please list places where you have been treated for alcohol or drug-related problems below:

Past Medical History

Past Surgical History

Family History

Psychosocial History