Questionnaire

NEW PATIENT MEDICAL QUESTIONNAIRE

In order to undergo our treatment, we first ask you to complete the medical form below. This will be reviewed by our providers before we contact you to arrange your appointment. We understand the importance of protecting your personal information and these forms will be treated with total confidentiality.

If you have any questions, please call our office at: 212-267-7283.

  • Patient Information
  • * required
  • * required
  • * required
  • * required
  • * required
  • * required
  • Emergency Contact
  • * required
  • * required
  • * required
  • * required
  • Drugs Currently Being Used
  • Most Recent Attempt to Withdraw
  • Psychological/Psychiatric Background
  • Past Medical History

    Regular use of medications?
  • * required