verb: to take action for your own health.
Complete the form as much or as little as you choose. Proactive therapy is a theory that humans need to take responsibility for their health, and they should have the tools to prepare their support team before a consultation. Electronic versions of this form are recommended to be sent electronically or delivered to the treating health provider prior to a scheduled consultation appointment to increase the value of time for all stakeholders. Support your provider’s office by keeping answers honest, short, to the point, and on a single page. Don’t ruin a good thing.
If you are suicidal or having a medical emergency: dial 911
National Suicide Prevention Lifeline: dial 1-800-273-8255
This is a free tool to help communication between humans and not for any medical advice. Email firstname.lastname@example.org to request the document be emailed.
Misty Jones, RN
(COPY BELOW, PASTE TO DOCUMENT, ENSURE IT PRINTS/SAVE ON ONE LINE & PRINT/EMAIL).
Date of Birth:
Tobacco use: How much?
Marijuana use: How much?
Illicit drug use: How much?
Alcohol consumption: how much?
Do you have children?
Do you have siblings?
Mother’s Name: Age: Education Level: Ethnicity:
Father’s Name: Age: Education Level: Ethnicity:
Marital Status of patient’s parents as a couple:
Are your basic needs met?
Are your emotional needs met?
Do you have physical pain?
Are you or have you ever had suicidal thoughts/plans?
Do you have emotional pain?
Have you personally been affected by a type of pain not listed?
Current prescribed medications:
Current non-prescribed medications:
Past Medical/Surgical History:
Past Emotional History:
Previous types of therapy:
How often do you exercise & what are your activities?
Where do you work and how often?
What are your major concerns?
Do you think you need a referral to a specialty department?
Do you think you need a new medicine?
Do you think you have an undiagnosed disease/disorder:
I am here to see you for: