Adult Health History
(Must use a PC or Laptop to complete this registration. Cannot use a smartphone to complete this registration. Thank you!)
Please list other medical conditions in the space below
Please list other major surgeries below
Because mental health and substance use disorders can be highly heritable, please indicate what you know about such conditions among the following blood relatives. If no history is known then click the button "No mental health or substance use problems".
(Eg. hyperactive, moody, happy, anxious, temperamental, etc.)
(Eg. 3rd of 5 children)
(Eg. loved, ignored, blamed, smart, etc)
(Eg. too strict, harsh, difficult, affectionate, close, unstable, too loose, etc)
(Eg. mother, spouse, friend, partner, etc)
Please provide details in section below
Thank you! We will contact you soon to schedule your appointment.