Psychiatric Intake Form Page 3
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11Current Over-The-Counter medications or supplements:
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Other Psychiatric Medications:
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Personal and Family Medical & Psychiatric History
Current Medical Problems:
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Women: Date of last menstrual period _____ Are you currently pregnant or think you might be? Yes ( ) No ( )
Are you planning to get pregnant in the near future? Yes ( ) No ( ) Birth control method: ___________________
# of pregnancies ________ # of live births __________ # of living children ____________
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