Nancywheelermd.com

N A N C Y C. W H E E L E R , M . D . , P . A. Instructions: Please fill out this form as completely as you can. Today's Date: ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ Relationship to You: ________________________________________ Pharmacy Please provide the name and phone number of the pharmacy you usually use. Name: ________________________________________ Provider Information: Please provide the names and phone numbers of any providers you see regularly. Please include physicians, therapists, and complementary health practioners. Name: ________________________________________ ________________________________________ ________________________________________ ________________________________________ (c) 2013 Nancy C. Wheeler, M.D. ~ 133 Defense Highway, Suite 114 ~ Annapolis, MD 21401 ~ 410-266-9181 N A N C Y C. W H E E L E R , M . D . , P . A. ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ Medical History Medical Issues: Please list all major medical problems, present and past _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Surgeries: Please list any operations you have had, and approximately when and why. _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Allergies: Please list any medication or foods to which you have had a bad reaction. Medication or Food ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ (c) 2013 Nancy C. Wheeler, M.D. ~ 133 Defense Highway, Suite 114 ~ Annapolis, MD 21401 ~ 410-266-9181 N A N C Y C. W H E E L E R , M . D . , P . A. Current Medications and Supplements: Please list all medications and supplements that you take. Includes any over-the-counter drugs that you take more than once a week. Medication Substances: Please mark whether you are currently using any of the following substances now or in the past. Only mark the substance if it was used or is being used without a prescription. Substance Psychiatric History: Hospitalizations: Please list any psychiatric hospitalizations you have had. Hospital ________________ __________ __________________________________________ ________________ __________ __________________________________________ ________________ __________ __________________________________________ (c) 2013 Nancy C. Wheeler, M.D. ~ 133 Defense Highway, Suite 114 ~ Annapolis, MD 21401 ~ 410-266-9181 N A N C Y C. W H E E L E R , M . D . , P . A. Past Medications: The medications below are sometimes prescribed for psychiatric problems. Please check any that you have taken in the past: (c) 2013 Nancy C. Wheeler, M.D. ~ 133 Defense Highway, Suite 114 ~ Annapolis, MD 21401 ~ 410-266-9181 N A N C Y C. W H E E L E R , M . D . , P . A. Past Therapists: Please list all mental health professionals whom you have seen. Name _______________________ ___________ ____________________________________ _______________________ ___________ ____________________________________ _______________________ ___________ ____________________________________ _______________________ ___________ ____________________________________ _______________________ ___________ ____________________________________ _______________________ ___________ ____________________________________ Family Psychiatric History: Please list any blood relatives who have been diagnosed with a mental illness. Relationship _______________________ ________________________________________________ _______________________ ________________________________________________ _______________________ ________________________________________________ _______________________ ________________________________________________ _______________________ ________________________________________________ (c) 2013 Nancy C. Wheeler, M.D. ~ 133 Defense Highway, Suite 114 ~ Annapolis, MD 21401 ~ 410-266-9181

Source: http://www.nancywheelermd.com/patient_information.pdf