48 Hour Pre-Screening Information
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2Schedule Date:
Date: ___________________________
Date: ______________________
New Hope I.B.H.C
Time: ______________________
48 hour Pre-Screening Information
Paid: _______________________
*Last Name: ____________________________________*First Name: ________________________________________
Text? Y
N
Primary Phone #:______________________
Email: ____________________________________
*D.O.B: ________________________ *SS#: _________________________ *Gender: ___________ Age: ____________
Address: _________________________________________________________________________________________
City: __________________________________ State: __________________ Zip Code: ___________________________
DUII: Dates: ________________________________ DL# ___________________________________________________
Substance Use (including nicotine)
SUBSTANCE
ADMINISTERED
FREQUENCY
AMOUNT
LAST USE
Medical:
Current and/or chronic physical/medical illnesses that may impact your stay? No
Yes
If yes, please explain: __________________________________________________________________________
History of medical problems, such as seizures, stroke, hypertension, diabetes, ambulatory issues? No
Yes
If yes, please explain: __________________________________________________________________________
List of Meds: _______________________________________
__________________________________
_______________________________________
__________________________________
Mental Health Diagnosis: ________________________________________________________________________
Medications : _______________________________________
__________________________________
_______________________________________
__________________________________
Emergency Contact: _______________________________________________________________________________
Relationship to you: ________________________________ Phone #: _______________________________________
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Parent category: Medical