Date Submitted ________________________
Intake Form
(For patients with scheduled appointments)
Name: _____________________________________Date of Birth: ___________________
S.S. #: _____________________________________Gender: ____ __________________
Ethnicity: ____________________________________ E-mail: _______________________
Phone #: ___________________________________ Cell Phone #: ____________________
Street Address: ________________________________________________________________
City/State: ______________________________ Zip Code: _______________________
Marital Status: Single Married Living w/partner Separated Divorced Widowed
List the people you live with and their relationship to you:

Are you currently Employed full time Employed part time Not working
Occupation: _________________________________________________________________
Employer: _________________________________________________________________
List the problem(s) for which you seek help:
1. ________________________________________________________________________ 2. ________________________________________________________________________ 3. ________________________________________________________________________


Insurance Company: ___________________________________________________________

I.D. # ______________________________________
Group # _________________________
Contact Phone # on back of Insurance Card: _______________________________________

Name of Insured (Policy Holder): ________________________________________________

Address of Insured: ____________________________________________________________
Birth Date of Insured: __________________________________________________________


Do you have mental health problems for which you’ve been treated? Yes No
If yes, complete the following:
Diagnosis Dates of Treatment
Name of Practitioner

Have you ever been hospitalized for a mental health problem? Yes No

If yes, please complete the following for the two most recent hospitalizations:
Diagnosis Dates of Treatment Name/Location of Hospital

Are you presently receiving psychiatric help? Yes No
If yes:
Date started: ________________________________________________________________
Type of treatment/frequency: ___________________________________________________
Name of practitioner/address:______________________________________________________

If you’ve taken any of the following medications, please indicate:

Helpful (Yes or No)
Other ________________________________________________________________________________ Other ________________________________________________________________________________

Do you have any allergies? Yes No
If yes, what are you allergic to? __________________________________________________

Are you bothered by problems with sleep?
Yes No
What is the nature of your sleep problem? _________________________________________


List any medications you take, prescribed or over the counter:

Do you have a Primary Health Care Provider ?
Yes No
Name of Primary Health Care Provider: _____________________________________________
Address: _____________________________________________________________________
Date of Last Exam:

Have you been hospitalized for a medical problem in the past year?
Yes No
If yes, please complete the following:
Name/Location of Hospital

For Women:
Are you currently breastfeeding an infant? Yes No

Are you pregnant or do you think you might be pregnant? Yes No
Are you planning to get pregnant in the near future? Yes No
Medical Screening:
Place a check next to any condition you have.
If you once had a condition but no longer do, provide the dates you had it.
If there’s a family history of an illness, place an F next to that illness.
Sexually Transmitted Disease
High Blood Pressure
Cancer Stomach or intestinal problems
Epilepsy or seizures

Liver Disease
Chronic Pain
Asthma/respiratory problems KidneyDisease
Heart Disease

Other _______________________
High Cholesterol
Other _______________________

Substance Use:
Have you been treated for alcohol or drug abuse? Yes No If yes, when ? _____________
What substance(s) did you abuse? _________________________________________________ _____________________________________________________________________________ What is the name and address of the agency/agencies where you received treatment? 1.___________________________________________________________________________ 2. __________________________________________________________________________ IV. SOCIAL HISTORY
Where were you raised? __________________________________________________________
If you have siblings, list their gender(s) and current age(s): ______________________________
At what age did you leave your childhood home? ______________________________________

What is the highest grade you completed? ______________________________________
List any degree(s) you’ve attained: ______________________________________
Thank you for completing our intake form.
Please bring it with you to your 1st appointment.
If you need assistance, contact our office manager, Steven Steele, at 718-383-3493, Ext. 4.


Microsoft word - chasemun2010 wha bg.doc

The Chase Model United Nations 2010 Committee Background Information Package World Health Assembly Topic: International Cooperation on Striking Phony Medicine Inside: A. Committee Introduction B. About The Topic a. Statement of The Problem b. Past Actions c. Analysis d. Possible Solutions e. Proposed Solutions f. Countries Status The World Health Assembly is the decision-making b


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