Form - Patient History

Please complete all required fields!

First Name(*)

Please let us know your name.

Last Name(*)

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Age(*)

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Date of Birth

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Email Address(*)

Please let us know your email address.

Phone Number(*)

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Street Address(*)

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City(*)

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State(*)

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Postal/ZIP Code(*)

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Country(*)

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What type of mental health practitioner is currently caring for you?(*)

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Practitioner's Name(*)

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Practitioner's Phone(*)

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What is your primary diagnosis given by your Practitioner?(*)

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What medications are you taking?(*)

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Have you ever attempted suicide?(*)

No
Yes Invalid Input

Are you currently suicidal?(*)

No
Yes Invalid Input

If you checked any of the boxes above, please provide details on your condition(s).

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Are you pregnant?(*)

Not Sure
No
Yes Invalid Input

Are you breastfeeding?

No
Yes Invalid Input

If you are allergic to any medications, please list them here.

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Have you or anyone in your family had an adverse reaction to anesthesia?

No
Yes
Not Sure Invalid Input

If you answered yes above, please describe the adverse reactions to anesthesia.

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Do you drink more than 2 drinks a day?

No
Yes Invalid Input

Do you use any recreational drugs?

No
Yes Invalid Input

If you answered yes above, please list type of drug and date of last use.

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Have you ever been treated for substance abuse?

No
Yes - drugs
Yes - alcohol
Yes - both Invalid Input

Patient Attestation: By submitting this form, I certify that I have completed this Patient Form to the best of my ability. I agree to seek immediate help should my symptoms worsen or I experience an increase in suicidal thoughts, feelings or urges. I authorize a representative from the Vitality Medical Infusions to contact me to discuss treatment options for my condition(s). I also understand that the staff of Vitality Medical Infusions will not start and maintain any prescribed treatment regimen if I am not currently under the care of a Mental Health Professional and maintain such care until the completion of my course of treatment.

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Form - Patient History

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