Medical History and Physical Examination    Step 6 of 9

(TO BE COMPLETED BY YOUR PHYSICIAN)

Dear Patient – It is important that you provide us with your medical information in order to receive quality integrated treatment. Please have your primary care physician complete this form. This form can be completed online. You can also download and/or print out this form and return it to:

• Attn: Dr. Henry Paul, Karen Horney Clinic, 329 E. 62nd Street, New York, NY 10065.
• Fax: 212-838-7158;
• Email: TheClinic@karenhorneyclinic.org.

Please email us if you would like a hard copy of this form  mailed to you.

Download and Print Form   Skip this form

If you are not having your physician complete your medical history and physical examination information at this time please check and sign below.

• I will not complete my medical history and physical examination information at this time:

NAME OF PATIENT *

Date *

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Physicians can complete your medical history and physical examination information by filling out the below form online or printing out and returning this form to: Karen Horney Clinic, 329 E. 62nd Street, New York, NY 10065. Fax: 212-838-7158; Email: TheClinic@karenhorneyclinic.org.

Patient's Name

Date

Home Address

Apt#

City

State

Zip Code

Home Phone #

Work Phone #

Sex

Gender

D.O.B.

Age

Height

Weight

BP

Temp

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Status of Current Health

A) Current Illnesses

B) Current Conditions

Past Health

A) Significant Illnesses

B) Hospitalizations

C) Accidents

Significant Family Illnesses: (If NONE, state so)

Current Medications: (Including Dosage, If NONE, state so)

Past History: (Neonatal History. List unusual findings such as cyanosis, jaundice, birth anomaly, infections, Rh factor, asphyxia, instrument delivery, prolonged labor, hemorrhage)

ILLNESSES (List age of onset. If any sequela, please list under comments)

Pertussis

Polio

Seizures

Measles

Eczema

Mumps

Scarlet Fever

Diptheria

Colitis

Rheumatic Fever

Chicken Pox

Asthma

Injuries

Operations

Hospitalizations

Enuresis

Allergies

Blood Dyscrasia

C.N.S. Infection, Diabetes

Involuntary Movements

COMMENTS (Include any other illnesses)

GENERAL IMPRESSION (Such as state of nutrition, obvious weight loss, chronically ill child, etc.)

Head and Neck

Eyes

Ears, Nose & Throat

Heart & Lungs

Thorax & Abdomen

Extremities & Joints

Skin

Abnormal Movements

A.J.

K.J.

T.J.

Plantar

Reflexes: Right

Reflexes: Left

ARE ANY OTHER TESTS, SUCH AS LABORATORY OR X-RAY WORKUPS, REQUIRED

ADDITIONAL COMMENTS

DIAGNOSIS

COVID VACCINATION STATUS:

• FULLY VACCINATED
• PARTIALLY VACCINATED
• NOT VACCINATED

NAME OF EXAMINING PHYSICIAN

Address

TELEPHONE #

SIGNATURE OF PHYSICIAN

Submit

When you have completed this form, you will be redirected to Step 7: Consent Form/Authorization For Release of Information