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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:

Social Security No.

Gender

Date of Birth



Zip Code:

Height

Weight

Primary Email Address

Cell Phone

Home Phone Number

Office Phone

Occupation/Former Occupation if Retired

Marital Status

Spouse Name if Married

PAYMENT INFORMATION
How Are You Paying?

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

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Have you ever withdrawn from these drugs or stopped drinking before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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