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Patient Information

    Patient Information

    Full Legal Name

    Employer Information

    Spouse’s Information (if applicable)

    Full Legal Name

    Emergency Contact Information

    Insurance Information

    PLEASE NOTE: we do not accept assignment from a secondary carrier. However, if you provide us with information and forms,we will kindly file your claim so that the secondary carrier can reimburse you.

    Responsible Party

    Please fill this session if someone other than the patient is responsible for the payment of services

    Patient Health History

    Directions to the patient: The Following information about your health is very important for us to provide you with the best possible care in a safe way. Incorrect information may be dangerous to your health. All questions must be answered completely and accurately. The health history questionnaire will become a part of the patient’s mental health record and will be considered confidential information.

    Physician’s Information

    • Do you have current health concerns?

    • Has there been any changes in your health during the last year? (If yes,
      please explain)

    • Have you ever been hospitalized for major operations or serious illness?
      please explain:

    • Date of the last visit to your doctor

    • Reason for Visit:

    • Are you currently receiving treatment or regular medical care by your
      doctor? (if yes, what are your conditions?)

    • Are you experiencing any of the following symptoms?
    • Using any type of drug (including but not limited to alcohol)?

    • Feeling anxious

    • Thoughts of harming yourself?

    • Thoughts of harming someone else?

    • Fear of going out in public?

    • Experiencing parental stress?

    • Feel as if someone is out to get you?

    • Feeling of helplessness?

    • Experiencing unusual amounts of headaches

    • Hearing voices

    • Having relationship problems?

    • Experiencing stress on the job?

    • Others, please list:

    • Do you have a family member with a drug or/and alcohol problem?
      (if yes, what family member(s)?)

    • Have you ever been treated for any of the following symptoms? (Please check all that apply):

    • Have you lost weight without dieting or gained weight recently?

    • Do you now use or have you ever used recreational drugs?

    • Do you currently smoke? (if yes, how many cigarettes a day?)

    • Do you currently consume alcohol? (if yes, how many drinks a day?)

    • What are other problems with your health that you know of?

    SIGNATURE OF PATIENT: I understand the need for these questions to be answered truthfully. To the best of my knowledge, the answers I have given are accurate. I also understand it is very important to report any changes in my medical status to Mr. Gary B. Bailey, and/or his associates at Alamance Life Works (EAP) PLLC, at the earliest
    time and as such I agree to do so. I give permission to Mr. Gary B. Bailey to obtain from my physician any additional information regarding my medical history needed to provide me the best mental health treatment possible.