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Out Patient Detox From
PERSONAL INFORMATION
PLEASE COMPLETE ALL QUESTIONS IF APPLICABLE TO YOUR SITUATION. WHEN YOU ARE DONE PLEASE HIT SUBMIT.
Today`s Date
First Name:
Last Name
Address
City:
State:
Choose a State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Alberta
British Columbia
Manitoba
Ontario
Saskatchewan
Social Security No.
Gender
Select One
Male
Female
Date of Birth
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
Zip Code:
Height
Weight
Primary Email Address
Cell Phone
Home Phone Number
Office Phone
Occupation/Former Occupation if Retired
Marital Status
Select One
Single
Married
Divorced
Separated
Spouse Name if Married
PAYMENT INFORMATION
How Are You Paying?
Select One
Credit Card
Cash
Financing with Lender like Reliance
Name of person paying.
REASON FOR DETOX
Describe reason You Want to Detox
REASON YOU TOOK SUBSTANCES FROM WHICH YOU WANT TO DETOX
Describe Reason Started Using Substance
DRUGS FROM WHICH YOU WANT TO DETOX
First Detox Substance
Date Started
Milligrams Used
Frequency Used
Prescribed
Yes
No
Second Detox Substance
Date Started-Purpose
Milligrams Used
Frequency Used
Prescribed
Yes
No
Third Detox Substance
Date Started-Purpose
Milligrams Used
Frequency Used
Prescribed
Yes
No
IF YOU WANT TO DETOX FROM ALCOHOL
TYPE OF ALCOHOL
Select
Type Of Alcohol
Beer
Wine
Liquor
Describe How Much You Drink And How Often
PREVIOUS WITHDRAWAL EXPERIENCE
Have you ever withdrawn from these drugs or stopped drinking before
Yes
No
If Yes, desrribe any withdrawal symptoms and when they started.
IF DETOX SUBSTANCES WERE TAKEN FOR PAIN
If taken for pain, what is solution after detox?
PATIENT PRIMARY CARE DOCTOR
Primary Physician and Contact Data
Date of Last 3 Visits to MD, Reasons, Results
TIMES IN THE HOSPITAL IN LAST FIVE YEARS
List Date, Reason and Result of Hospital Stays in Past Five Years
FOOD, DRUG OR OTHER ALLERGIES
LIST OF FOOD, DRUG AND OTHER ALLERGIES YOU HAVE
SEIZURES, DT`S OR BLACKOUTS
Ever had a Seizure, Hallucinations, DT`s or Blackouts?
Yes
No
If yes, date, treatment, result
EXERCISE TYPE AND AMOUNT
IF YOU EXERCISE, HOW AND HOW OFTEN
LIST OF OTHER DRUGS/SUPPLEMENTS TAKING NOW
Drug/Sup
Date Started
Dose/Freq
Reason
Prescribed
Yes
No
Drug/Sup
Date Started
Dose/Freq
Reason
Prescribed
Yes
No
Drug/Sup
Date Started
Dose/Freq
Reason
Prescribed
Yes
No
IF TAKING BLOOD PRESSURE MEDICINE
If on Blood Pressure Med Please Provide Last Reading
LIST OF DRUG/SUP THAT WERE TAKING IN PAST FIVE YEARS BUT NO LONGER
Drug/Sup
Date Started/Ended
Dose/Freq
Reason
Prescribed
Yes
No
Drug/Sup
Date Started/Ended
Dose/Freq
Reason
Prescribed
Yes
No
Drug/Sup
Date Started/Ended
Dose/Freq
Reason
Prescribed
Yes
No
DEPRESSION
Do you suffer from depression?
Yes
No
If Yes, Explain How You Are Dealing With Depression
SUICIDE ATTEMPTS
Have you considered or attempted suicide
Yes
No
If Suicide Attempt Provide Details
TREATMENT BY A PSYCHIATRIST OR PSYCHOLOGIST
Have You Been Treated by a Psychiatrist or Psychologist
Yes
No
If Yes, Please Provide Who, Frequency and Treatment
PREVIOUS DETOX OR REHAB
Have you gone to a detox/rehab before?
Yes
No
If yes, list in or outpatient, reason, date and location.
ALCOHOL, TOBACCO AND MARIJUANA USE
Do You Smoke?
Yes
No
If Yes, Frequency and Amount
Do You Smoke Marijuana?
Yes
No
If Yes, Frequency and Amount
Do You Drink Alcohol?
Yes
No
If Yes, Frequency and Amount
MEDICAL PROBLEMS THAT YOU HAVE (Check all that apply)
Arteriosclerosis:
Stroke:
Fatigue
Heart Problems:
Diabetes:
Anxiety Disorder:
Decreased Sex Drive
Depression
Anemia:
Eating Disorders
Liver Problem:
Anger
Insomnia
Sleep Apnea
Cirrhosis of the Liver:
Kidney Problem:
Hepatitis:
High Blood Pressure:
Low Blood Pressure:
Sleep Problems:
Breathing Problems:
Lung Problems:
Problems with Concentration
Migraines
Tired
Irritable
IF YOU HAVE ONE OR MORE OF THE ABOVE CONDITIONS
Were any above conditions checked?
Yes
No
If Yes, Provide Treatment and Result
DIABETIC
If diabetic, do you take insulin?
Yes
No
IF FEMALE ARE YOU PREGNANT
If Female, Are You Pregnant
Yes
No
If Yes, What Month
ANY ADDITIONAL INFORMATION YOU WANT TO GIVE THE DOCTOR
Any More Data For The Doctor?
END OF MEDICAL FORM
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