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Step 2 - Adult Health History

Adult Health History

(Must use a PC or Laptop to complete this registration. Cannot use a smartphone to complete this registration. Thank you!)

Psychiatric History

Substance Abuse

Medical History

Please list other medical conditions in the space below
Please list other major surgeries below

Family History

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".

Social History

(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.

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