Personal Information Instructions
Please fill out this form as completely as you can. Print your answers. Today's Date Marital Status First Name Ethnicity Last Name Gender [ ] Male [ ] Female Date of Birth Occupation Address and
Please give your home address. Please indicate by circling the appropriate letter whether I can
leave a full message (“M”), callback number only (“C”), or no message at all (“N”).
Home Phone Cell Phone Work Phone Emergency
Please tell me the name of someone to contact in case of an emergency. If any information is
the same in the table above, you can write "Same". Relationship Home Phone Cell Phone Work Phone Insurance
Although I do not participate with any insurance companies, it is often helpful to me to have your insurance information in case you need tests or hospitalization.
Primary Plan Secondary Plan Subscriber Subscriber Referral source
Please tell me who suggested that you see me.
Relationship to Pharmacies
Please provide contact information for pharmacies you plan to use to fill your prescriptions.
Pharmacy Location Pharmacy Location Doctors and Therapists Instructions
Please provide contact information for all doctors (including psychiatrists and therapists) whom you see regularly. Please also include past psychiatrists and therapists. Continue on back if necessary. Type of doctor Type of doctor Type of doctor Type of doctor Type of doctor Type of doctor Type of doctor Type of doctor Type of doctor Medical History
Please list all major medical problems and treatments. For example: diabetes, diet &
medication; breast cancer, lumpectomy & radiation. Please include head injuries. Continue on back if necessary. When diagnosed Treatment(s) Date(s) of Treatment(s) Surgeries
Please list any operations you have had, when and why. For example: appendectomy, 1990,
appendicitis. (No need to repeat operations listed above.) Continue on back if necessary.
Operation Allergies &
Please list any medications or foods to which you have had a bad reaction (rash, e.g.). Please
include any problems with anesthesia. Continue on back if necessary.
Medication or Food Reaction
Please list all medications and supplements that you take. Include drugs that are prescribed by a Medications &
doctor, vitamins and herbal supplements, and over-the-counter drugs you take frequently.
Supplements Medication or Supplement Frequency Reason you take it Substances
Please check whether you use or have ever used any of the following, prescribed or not.
Where multiple substances are listed, please circle all that apply. Continue on back if necessary.
Opioids (heroin, methadone, pain medication)
Please check any of the following problems or tests you have had in the last year. If given a
choice (weight loss or gain, e.g.), please circle applicable symptom(s). Where appropriate, please indicate what body part was tested (X-ray: chest, e.g.).
[ ] Persistent loss of sensation/numbness
[ ] Jaundice (yellow skin or eyes) [ ] MRI of:
Psychiatric History Hospitalizations
Please list any psychiatric hospitalizations you have had. Continue on back if necessary. Hospital When admitted/discharged Reason hospitalized Past Medications
Please check any of the following medications that you have taken in the past.
Please check any of the following problems that you have had in the last month.
[ ] Trouble concentrating [ ] Interacting less
[ ] Can’t make decisions [ ] Impulsive behavior
[ ] Guilt over bad deeds [ ] Don't trust people
[ ] Deserve punishment [ ] Thoughts not your own [ ] Can't throw things away
[ ] Trouble getting started [ ] Worry about health
[ ] Thoughts being blocked [ ] Afraid to get fat
[ ] Life not worth living [ ] Messages from TV/radio [ ] Making yourself vomit
[ ] Interpersonal trouble [ ] Thoughts of suicide
[ ] Alien force moving your [ ] Using exercise or laxatives
Family Psychiatric History Family History
Have any of your blood relatives been diagnosed with a mental illness? Please indicate their
relationship to you and check all that apply. Continue on back if necessary.
Relationship to you Diagnosis (check all that apply) Treatment (check all that apply if known)
Helen is the managing director of a small company advertising lesser-known musical artists on the Internet though a (fictional) website called www.lesserknownartist.com. The business model is simple. Her company obtains income from each musician listed on her website that is visited by a person through a hyperlink on www.lesserknownartist.com. The company also obtain a small percentage of any merc
Stephen Murray, M.D., Ph.D. Clinilabs, Inc. Residence 1408 Schodack Landing Road Current Position Chief Medical Officer Clinilabs, Inc. January, 2011 - Present Previous Positions Chief Medical Officer Clinical Development and Regulatory Affairs Therapeutic Area Team Leader, Schizophrenia, Bipolar and Cognition Pfizer Global Pharmaceuticals, Inc. Worldwide Medic