Priscilla Ray, M.D.

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PSYCHIATRIC ASSOCIATES

DATE:

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DOB:             /        /

LAST NAME:

 

FIRST:

 

MI:

 

AGE:_____

SEX:        MALE / FEMALE

SS #

 

 

 

Address:

 

City

 

State:

 

Zip:

 

 PHONE:

 

WORK #:

 

CELL:

 

REFERRED BY:

 

PURPOSE:

 

 

EMPLOYER:

 

SPOUSE'S NAME

 

DOB:

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PHONE:

 

EMERGENCY CONTACT

 

RELATION

 

PHONE:

 

Check

Illness

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Illness2

Question

Answer:

 

Seizure

 

Neurological Disease

Do you smoke?

YES   /   NO

 

Cancer

 

Eating Disorder

If so how many packs per week

 

 

Diabetes

 

Schizophrenia

Drug Use (Non-Prescription)?

YES   /   NO

 

Thyroid Disease

 

Sexual Problems

If so please list drug type:

 

 

Anemia (low blood)

 

Sleep Problems

How many times per week?

 

 

High Blood Pressure

 

Migraines

Alcohol Usage?

YES   /   NO

 

Heart Disease

 

Depression

How many drinks per week?

 

 

Breathing Problems

 

Panic Disorder

 

ADD

 

Nerves

List All:

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Alcoholism

 

Drug Abuse

List all allergies:

 

Anxiety

 

Urinary Tract Problems

 

Stomach/Bowl Disease

 

Prostate Problems

 

 

 

Joint/Back Problems

 

HIV or AIDS

List all medications

 

Manic Depressive Illness

 

Other (list below)

 

Pregnancy Problems

 

 

 

 

 

Female Problems

 

 

List surgeries/hospitalization

 

Learning Disorder

 

 

 

 

Previous psychiatric treatment/illness:

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