TREATMENT APPLICATION FORM

Treatment Application Form

First Name:
Last Name:
Email:
Phone:
Cell / Alternate Phone:
Age:
Height:
Weight:
Emergency Contact
Address:
Primary Drug of Addiction:
Brief history of your addiction or condition you are seeking treatment for.
BriefList of Medications: Include daily dosages:
List of all non-prescribed medications / or street drugs used in the past 30 days.
List of medications prescribed, but, not taking:
List of all supplements / performance enhancers currently taking / or have taken in past month.:
List of all foods / medications you are allergic to.:
List any major surgeries you have had, including approximate date.:
Do you drink alcohol?:
if yes, how much and how often?:

Do you smoke?:

If yes, how much per day?
Do you have a history of myocardial infarction or heart disease? If so, explain.
Do you have hypertension or hypotension?:
Do you have a history of seizures?:
Do you have a history of vascular disease, including aneurysms? If so, how is it being treated?:
Do you have a history of embolism, problems w/ blood clotting or recent trauma, including the pelvis or legs? If so, please explain?
Do you have diabetes?
If yes, are you insulin dependent?:YESNO
Do you have fainting spells or get dizzy upon getting up suddenly? If so, please explain.:
Do you have a history of ulcerate colitis, Cronin's Disease, bleeding or peptic ulcers? If yes, please explain.:
Do you have any type of hepatitis, including abnormal liver function tests, hepatitis C, primary biliary cirrhosis, elevated serum ammonina levels, etc . . .? If yes, please explain.:
Do you consider yourself to be depressed? If yes, please explain.:
Have you ever tried to commit suicide? If yes, please explain.:
Have you ever been admitted to a psychiatric hospital? If yes, please list approximate dates and condition you were treated for.:
Do you have any type of brain damage, including traumatic or closed head injuries w/ or w/o unconsciousness or seizures? If yes, please explain.:
Are you asthmatic? If yes, do you use an inhaler?:
Do you suffer from or have any of the following physical conditions? Check all that apply.

Diabetes:
Hepatitis A, B or C:
History of Ulcers:
Slow Heart Rate:
Jaundice:
Thyroid Problems:
Heart Disease:
Respiratory Problems:
Loss of Menstruation:
Excessive Menstruation:
Swelling Joint Pain:
Varicose Veins:
Back Problems:
Nausea:
Dizzy:
Spells:
High Blood Pressure:
Renal Disease:
Nerve Damage:
Constipation:
Stroke:
Bleeding:
Stomach Problems:
Liver Problems :
History of Seizures:

Urinary Problems:
Heart Problems:YESNO
Low Blood Pressure:
Asthma :
Painful Menstruation:

Cancer:
Fainting :
Numbness :
Diarrhea :
HIV Positive / Aids Shaking:
Tuberculosis:
Shortness of Breath :
Muscle Spasms :
Heartburn:
Obesity:
Additional Comments:
If you have an EKG, Lab Test or Medical records please attach here
ACCEPTED
When you are ready and you have finished filling in all the required fields, select ACCEPTED and then the SUBMIT button. Check that you do not receive an error message to ensure that the information has been sent properly.