Medical Form – Self-Report    Step 5 of 9

(TO BE COMPLETED BY PATIENTS)

Dear Patient – It is important that you provide us with your medical information in order to receive quality integrated treatment. Please complete the below form. If you would prefer to complete a hard copy of this form please print this form out or contact us at our secure email address, TheClinic@karenhorneyclinic.org if you would like a copy mailed to you with a self-addressed stamped envelope.

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Has a Doctor EVER told you that you had any of the following conditions?

CURRENT Medication Information

Include all current medication-Psychiatric/Non-Psychiatric, Prescription/Over-the-counter drugs/Herbal)
For each medication include
  • Medication
  • Reason for Taking
  • Dosage/Frequency and When taken (Dates/Length of time)
  • Side-effects
  • Helpful? Yes or No
  • Prescriber

If not taking any medication or supplements, indicate None

Medication History Information


(As best as possible, list all additional medications taken for psychiatric or substance abuse issues in the past)

For each medication include
  • Medication
  • Reason for Taking
  • Dosage/Frequency and When taken (Dates/Length of time)
  • Side-effects
  • Helpful? Yes or No
  • Prescriber

If not taking any medication or supplements, indicate None

Once you have completed this form, you will be redirected to Step 6 Medical History and Physical Examination (download to be completed by your physician)