Valley Forge Medical Center Admissions Form

* Name of person filling out this form:

* Relationship to patient

* E-mail address:

Fields marked with an * asterisk are required fields

Street address:

City:

State:

Zip:

Phone numbers:

Home:

Cell:

Patient Information

* Name of patient:

Marital status:

* Patient age:

Patient street address:

City:

State:

Zip:

I am having a problem with:

Alcohol	Last used
Other drugs	Please specify:
Both	Last used:
Prescribed medication(s)	Please specify:
Chronic Pain	Please specify:

Have you had prior treatment for alcohol or other drugs?

If yes, where/when:

Yes

Do you have other medical or psychiatric problems?

If yes, please specify:

Yes

ADD/ADHD

Anxiety

Chronic pain (arthritis, fibromyalgia, other)

Depression

Diabetes

Eating Disorder

Hypertension

Neuropathy

OCD

Other

If other, please specify:

Are you taking prescribed medications?

If yes, please specify:

Yes

Are you currently under the care of:

If yes, please specify name:

Employee Assistance Professional

Psychiatrist

Psychologist

Therapist/Counselor

Pain Management

Methadone Clinic

Please indicate method of payment:

Who will be the guarantor of the account?

Please provider your insurance information below:

Insurance company name:

Insurance company phone number:

Subscriber name:

Subscriber date of birth:

Patient date of birth:

Relationship of subscriber to patient:

Member ID number:

Name of subscriber employer: