Treatment Application Form
Cell / Alternate Phone:
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?: YESNO
if yes, how much and how often?:
Do you smoke?: YESNO
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?:YESNO
Do you have a history of seizures?: YESNO
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? YESNO
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.
Hepatitis A, B or C:YESNO
History of Ulcers:YESNO
Slow Heart Rate:YESNO
Loss of Menstruation:YESNO
Swelling Joint Pain:YESNO
High Blood Pressure:YESNO
Liver Problems :YESNO
History of Seizures:YESNO
Low Blood Pressure:YESNO
HIV Positive / Aids Shaking:YESNO
Shortness of Breath :YESNO
Muscle Spasms :YESNO
If you have an EKG, Lab Test or Medical records please attach here
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.