30320 Rancho Viejo Rd., Suite 102
San Juan Capistrano, CA 92675
Tel: 949-481-8414
Fax: 949-481-8415
 
Confidential Patient Information Form
 
 
Complete all sections
 
A.
PATIENT INFORMATION
First Name
Middle Name
Last Name
Address
City
State
Zip
Home Phone
Work Phone
Cell Phone
Best way to reach you
Email Address
Driver's License Number
State
Expiration Date
Social Security Number
Sex
Date of Birth
Age
Ethnicity
Handedness
Marital Status
Education:
Highest Degree Completed
Major(s)
Any difficulties (behavioral/academic) while in school?
 
Ever been diagnosed with Learning Disability?
Currently attending college or university?
 
Occupation
Name of Company
How long?
Retired?
Disabled?
Annual Income?
 
B.
REFERRAL INFORMATION
Who referred you?
Title/Position
Phone Number
Address
City
State
Zip
What is the reason for the referral
Were you injured on the job (Worker's Comp)?
Are you represented by an attorney?
Describe the problems you’ve been experiencing and for how long?
What do you hope to learn from this visit/or evaluation?
 
C.
MEDICAL HISTORY
Do you have any medical conditions (e.g. high blood pressure, diabetes, cancer, etc.)?
Ever had meningitis?
Scarlet Fever?
Any toxic exposure,  such as lead, solvents?
Do you have any vision or hearing problems?
Do you wear glasses or hearing aids?
Any family history of medical or neurological disorders? (e.g. Alzheimer, Parkinson’s, stroke)?
Have you ever been in a motor vehicle or motorcycle accident or fall?
Ever Injured Your Head?
Ever had seizures or convulsions?
Ever had a stroke?
Ever had dizziness, migraine headaches, nausea (circle)?
What was the date of your last physical exam?
How is your overall physical health?
 
List the Medications You Are Currently Taking
Medication
How Long?
Dosage (mg)
#/day
Click here to add more Medications
 
D.
PSYCHIATRIC/EMOTIONAL HISTORY
Ever seen a mental health worker (psychologist, psychiatrist, counselor)?
Ever been hospitalized for emotional problems?
 
Ever attempted suicide?
Are you currently taking any medications for emotional problems?
 
Any family history of psychiatric or emotional illnesses?
Any family history of psychiatric hospitalizations?
Any family history of suicide?
 
E.
DRUG/ALCOHOL USE
Do you drink alcohol?
 
Do you use illicit drugs?
Any family history or alcohol or drug use?
 
F.
HISTORY OF LEGAL PROBLEMS OR ARRESTS
Ever been arrested?
Signature
 
 
Step 1: Click Signature to sign this form.
Step 2: Click Finalize to put the signature on this form.
Step 3: Enter the date.
Step 4: Click Submit to send the form.