Medical History

Please fill out the following form
and submit online. If no relevant information, please indicate

Who referred you to MSP Psych Services or how did you hear about us?

Name of psychiatrist and clinic:

Date of last visit

Reason for leaving

Name of family doctor if they are prescribing psychiatric medication:

Name of therapist/counselor and clinic:

Diagnosis (e.g. depression, anxiety, ADD, etc.):

If you have an ADD diagnosis, when did formal testing occur:

Who provided the ADD testing:

Past psychiatric hospitalizations (where, when, reason):

Past suicide attempts (how many and when):

Self-injurious behavior (e.g. cutting on self):

Physical, sexual, or emotional abuse:

Case worker name and phone number:

Medications

Current pharmacy (name & address) and current medication with dosing instructions:

Past medication trials and outcome (list medication names):

If none, please indicate

Height, Weight, and Allergies

Are you either of the following?

Pregnant

Breastfeeding

Current health issues (e.g. asthma, migraines, diabetes, etc.):

Past surgeries (include year of surgery):

Thanks for submitting!