MEDICAL HISTORY AND PHYSICAL EXAMINATION

(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: 

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

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

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.

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