NEW PATIENT MEDICAL QUESTIONNAIRE

In order to undergo our treatment, we first ask you to complete the medical form below. This will be reviewed by our providers before we contact you to arrange your appointment. We understand the importance of protecting your personal information and these forms will be treated with total confidentiality.

If you have any questions, please call our office at: 212-267-7283.

Patient Information

Sex

Marital Status

Address

Emergency Contact

Other Relevant Personal Remarks:

Drugs Currently Being Used

Most Recent Attempt to Withdraw

Craving scale while “clean":

Methadone or Suboxone Maintenance?

Psychological/Psychiatric Background

Have you ever received psychiatric treatment?

Prior suicide attempts?

Past Medical History

Regular use of medications?

Allergies (Medications, Food, etc.)?

Past Surgeries?

Hospitalization in the last two years?

Emergency room visits in the last year?

Accidents? (work, car etc)

Head Injuries?

Loss of consciousness?

Seizures?

Heart disease?

Lung disease?

Liver disease / infections?

Kidney disease / problem?

Diabetes?

Ulcers?

High Blood Pressure?

Asthma or shortness of breath?

Pregnancy?