first appt:
Dx:
Benna Z. Sherman, Ph.D.
Licensed Psychologist
-------
Patient Information Form
Mr./Mrs./Ms./Dr. ___________________________________
Address: ______________________________________ Phone #: (home)_______________________
______________________________________ (work)________________________
______________________________________ (pager/cellular)_________________
Marital/partnership status: ________________________________ Date of Birth: _______________
Household members (name, relationship, date of birth):
_______________________________________ ____________________________________
_______________________________________ ____________________________________
_______________________________________ ____________________________________
Employer: ____________________________________ position: _____________________________
or
Current school: ________________________________ grade: ____
Years of Education/Degree__________________
Referred by/Knew about from: ____________________________
Primary care physician: ______________________________ Phone #: ________________________
Any medical problems/conditions?
________________________________________________________
Medications? __________________________________________________________________________________
Allergies?____________________________________________________________________________________
Date of last medical exam/evaluation ___________________
Prior therapy? __ yes __ no with whom? _______________ when? _______________
Financial responsibility for psychological services
Responsible party, if different from patient: _____________________________________
Address and phone, if different from patient:
____________________________________
____________________________________
phone #: (H)_________________(W)_________________
(9/09)
