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New Patient Medical History

Physical Health History

What three physical/medical problems, diseases, or surgeries are most significantly impactful to you? (Leave blank if none)

Mental Health History

What Mental Health Conditions are you currently coping with?

Have you ever been, or are you currently, followed by a medical provider (psychiatrist, nurse practitioner, or PA) for management of your psychiatric medication treatment?
Have you ever been hospitalized for psychiatric reasons?
No
Yes, once
Yes, twice
Yes, three or more times

Continue to New Patient Mental Health History (Continued)

© 2024 by Dr. Reed J. Robinson, Ph.D., ABPP, MBA

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