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:
- 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.