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Apply for Treatment
Emergency Contact 1: Please put full name, address, phone number, and email address
Emergency Contact 2: Please put full name, address, phone number, and email address
List specific addictions and usage amount
List your history with addictions including your current addictions and all other past addictions
List all OVER THE COUNTER supplements and medications you are taking
List all PRESCRIBED medications or prescriptions you are taking or use
List any PRESCRIBED medications you are NOT CURRENTLY taking that you are prescribed
List all of your food/medicine allergies
List all unprescribed medications or street drugs you have taken in the past 30 days
Have you ever been diagnosed with a mental illness. If YES please list them.
List all major surgeries you have had. Please put an approximate date and reason for the surgery.
What is your last blood pressure reading
What is your resting heart rate
If you drink alcohol please list how much and how often
Are you a cigarette smoker? If YES how much and how long?
Have you ever been admitted to a psychiatric hospital?
If YES please list approximate dates and conditions treated
Do you have hypertention or hypotension
Do you have a history of myocardial infarction or heart disease? If YES please explain.
Do you have a history of seizures? If YES please explain.
Do you have history of vascular disease including aneurysms? If so how is it being treated?
Do you have a history of embolism, problems with blood clotting, or recent trauma to the body including the pelvis or legs? If YES please explain.
Do you have diabetes? If YES are you insulin dependent?
Do you have hypoglycemia? If YES please explain.
Do you have fainting spells or get dizzy when getting up suddenly? If YES please explain.
Have you ever had surgery to your gastrointestinal tract or have a history of disease including ulcerative colitis, Crohn's Disease, bleeding or peptic ulcer? If YES please explain.
Do you have any type of hepatitis including abnormal liver function tests, hepatitis C, primary biliary cirrhosis, elevated serum ammonia levels, etc.? If YES please explain.
Do you get nauseous easily? If YES what has triggered this reaction?
Have you ever coughed up or vomited blood? If YES please explain.
Do you have insomnia? 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.
Do you have any type of brain damage including traumatic or closed head injury with or without unconsciousness, or seizure? If YES please explain.
Are you asthmatic? If YES do you use an inhaler?
Do you suffer from or have you suffered from any of the following physical conditions? (Check all that apply.)
Shortness of Breath
Low Blood Pressure
History of Ulcers
Loss of Menstruation
High Blood Pressure
NONE OF THE ABOVE
Is there anything else you would like to tell us?
How did you hear about us?