top of page

ABOUT
NEW PATIENTS
EXISTING PATIENTS
SERVICES

MEDICAL CANNABIS PROGRAM

APPOINTMENT REQUEST

Gravel Road into the Forest_edited.jpg

Adult History Form

First name*

Last name*

Gender

Birthday*

Month

Day

Year

Email*

Phone*

Address

Address

Country/Region*

Address*

City*

Zip / Postal code*

Name of your Pharmacy*

Mental Health History Status

What problems are you seeking help for?*

Past Mental Health Treatment

Have you ever been hospitalized for psychiatric reasons?*

Yes

No

Have you ever had outpatient treatment by a psychiatrist?*

Yes

No

Have you ever received counseling or psychotherapy in the past?*

Yes

No

Please List any psychiatric medication you have taken or are taking:

Medications, dates, benefits & side effects

Please check all that apply

Depressed mood

Lost or gained weight

Not enough sleep

Too much sleep

Sluggish

Agitated

Never tired

Cannot concentrate

Afraid to leave home

Inflated self esteem

Feel guilty or worthless

Excessive talking

Racing thoughts

Easily distracted

Over working yourself Impulsive behavior

See/hear things that are not real

Suspect things may not be real Tense/unable to relax

Excessive worry

Panic attacks

Thoughts of death or suicide

Unreasonable fear

Fear of social situations

Repetitive thoughts/behavior

Upsetting memories

Recent loss/grief

Work/school problems

Violent thoughts/behaviors

Self harm

Anger outburst

Careless, high-risk behavior

Financial problems

General Medical History

Please list any medical problems you may have below

Please list any serious medical procedures you have had in the past

Are you on any medications for any general medical problems you may have?

Yes

No

Do you have any allergies to medications?

Yes

No

Alcohol, Drug, and Tobacco Use

Describe your use of alcohol*

Describe your use of recreational drugs*

Describe your use of tobacco*

Family Medical History

List any history of illness (mental or other) and substance abuse among blood relatives

Mother’s side*

Father’s side*

Social History

Birth place*

Where did you grow up?*

Did your parents get divorced as a child?*

Yes

No

Father’s occupation growing up*

Mother’s occupation growing up*

How many siblings do you have?*

What were your grades in grade school?*

What were your grades in High School?*

Did you go to College?*

Yes

No

Do you have any children?*

Yes

No

Consent to Treatment

First Name*

Last Name *

We are treating you and we will do our best to accurately diagnose you and design a comprehensive treatment plan that will enable you to continue with a normal emotional development. This may include recommendations of therapy, or medications. This is all part of the service of a mental health professional. We will also work with your primary care physician to assure coordination of care.

Please Initial*

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

You are our client and have confidentially rights. Confidentiality does not apply under certain situation: We are obligated by law to report any suspicion of child abuse. This includes physical or sexual abuse. Also, we have a duty to protect if we suspect anyone is in danger of killing themselves or has made threats to hurt someone else.

If I require or think it is in your best interest to communicate with an outside source, I will request a release of information. To assure good therapeutic care, frequent appointments are required. A new evaluation will be required for any inactive client to be seen. Considered inactive after 12 Months.

Please Initial*

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

I am aware that I may stop treatment with this mental health professional at any time.

Please Initial*

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

I am aware that if I attempt to call my my provider through phone, email, text or any other form of communication over the internet, my information may not be completely secure. In the event that my information be intercepted, this clinic is not responsible for the breach of patient privacy. Below are the approved contact means to leave messages on or respond to if contacted.

Phone*

Email*

Please Initial*

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Client Name (Please Print)*

Client Signature*

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

SOCIAL:

CONTACT

PHONE: 612-708-7562

FAX : 507-738-1963

3507 Lyndale Ave S. Minneapolis, MN 55408

NAVIGATION

About
Services
Accepted Insurance
New Patient
Existing Patient

You may receive encrypted emails from ‘Pau Box’ on behalf of Miles Med Management.

Copyright © 2025 Mental Health Meds. All Rights Reserved.

bottom of page