Are you taking any medicines (prescribed or over-the-counter) or herbal products? yes no If yes, please list these below. EXAMPLE Medicine Medicine Medicine Medicine Medicine Medicine #1 #2 #3 #4 #5 #6 If you Name of medicine Celexa need more How many 40 mg space, milligrams (mg)? please attach How many pills do one you take at a time? How many times a once day do you take this medicine? What time of day morning do you take this medicine? depression What does this medicine treat? Name of Dr. John prescribing doctor Doctor another sheet of paper. Do you have any allergies? yes no Have you ever had a bad reaction to medicine? yes no If yes to either question, please describe: Date: Time: Client signature:
Are you taking any medicines (prescribed or over-the-counter) or herbal products? yes no If yes, please list these below. EXAMPLE Medicine #1 Medicine #2 Medicine #3 Medicine #4 Medicine #5 Medicine #6 Name of medicine Celexa How many milligrams (mg)? 40 mg How many pills do you take at a time? one How many times a day do you take this medicine? once What time of day do you take this medicine? morning What does this medicine treat? depression Name of prescribing doctor Dr. John Doctor If you need more space, please attach another sheet of paper. Do you have any allergies? yes no Have you ever had a bad reaction to medicine? yes no If yes to either question, please describe: Client signature: Date: Time:
adult-behavioral-health-intake.docx