Medical Record-Supplemental Medical Data (Page 4 of 4) in pdf

Medical Record-Supplemental Medical Data Page 4

Write any other medical problems you have that are not listed above:

Please list any medications that you are currently taking, including prescriptions, over the counter medications, and herbal medications:

List ANY surgeries that you have ever had, including the year the surgery was performed:

SOCIAL HISTORY:

Do you drink alcohol?

If yes, how many drinks per day?

How many cups of caffeinated coffee do you drink per day?

How many caffeinated sodas do you drink per day?

How many energy drinks do you drink per day?

Do you currently or have you ever routinely smoked cigarettes?

On average, how many packs per day?

For how many years?

If you quit, in what year did you quit?

Do you take any illicit drugs?

If yes, please list:

PSYCHOLOGICAL HISTORY:

Do you currently feel depressed?

Have you lost interest in activities that normally bring you pleasure?

Do you have anxiety?

Have you ever seen a psychiatrist or any other type of counselor?

If yes, what were you treated for?

Yes

_/day

Yes No

_/day

Yes No

Please use the rest of this form for any other comments about your sleep that was not already covered.

Medical Record-Supplemental Medical Data Page 4