Any allergies? ( ) Yes ( ) No If yes, please explain: Any surgeries? ( ) Yes ( ) No I am currently taking the following medications: Date of last physical and the results of the examination: examination, doctor’s name, Date Client’s Signature _________________________________ _________________ Reviewed by Dr. Townsel Date
Any allergies? ( ) Yes ( ) No If yes, please explain: Any surgeries? ( ) Yes ( ) No I am currently taking the following medications: Date of last physical examination, doctor’s name, and the results of the examination: Client’s Signature Date _________________________________ _________________ Reviewed by Dr. Townsel Date
psychhistory.docx