History




































    Chief Complaint






    PRIOR ATTEMPTS TO CORRECT PROBLEMS/PRIOR PSYCHIATRIC HISTORY:

    PsychiatristNeurologistCardiologistAlternative/Holistic/NaturopathicTherapyPsychiatric Inpatient HospitalizationOutpatient Treatment ProgramOther

    Prenatal and Birth Events










    Seizures or seizure like activityPeriods of spaciness or confusionConcussionWhiplashLoss of consciousnessHead traumaStitches on face or head

    Dietary/Exercise Information










































    Alcohol/Drug History












    yesno

    yesno

    yesno



    yesno

    Family History

    Biological mother's history:

























    Biological father's history:





























    Psychological Information


















    Spiritual Information












    Mental Status Examination
























    Neuropsychiatric Symptom Checklist

    Please review the symptoms below and place a check in the appropriate box if you or any of your family members have had the problems listed:


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