MindCompanion.ai

My Profile

Below are forms to provide us with information on your life, relationships, history, and more so we can provide the best treatment possible.

Patient Identity

First Name

Middle Name

Last Name

Date of Birth

Marital Status

Height

Weight

I am adopted:

Yes

Caffine Beverages:

Yes

Use Drugs:

Yes

Gender Identity

Gender Assigned at Birth

Gender Identity

Were you assigned a different gender at birth?

Would you describe yourself as transgender?

Pronouns

Contact Details

Business Street Address 01

Business Street Address 02

City

State

Zip

Home Phone Number

Office Phone Number

Cell Phone Number

Household Occupants

Please list all members of your household and include all children.

Name

Relationship

Reason for Therapy

Did anything or any life event trigger or casue this problem for you?

Yes

Please Describe what happend?

Has anyone else been encouraging / pressuring / forcing you to seek help?

Yes

Have you participated in therapy before?

Yes

Number of times?

What was the reason for seeking therapy in the past?

Partnership / Marital Relationship(s)

(Only complete this section if you are over 18)

How many times have you lived with someone in a committed relationship or been married?

If married or living with a significant other, how long have you been together or married?

How well do you and your spouse / significant other get along?

Very Poorly

Poorly

Okay

Pretty Well

Very Well

Are you satisfied with your current spouse/partner?

Yes

Are you satisfied with your current relationship with your children?

Yes

What do you consider to be teh purpose of marriage or your current relationship?

Medical History

Most recent Covid vaccine

Most recent flu vaccine

Medication Name	Dosage	Purpose	Start Date	Discontinued Date	Options
Floxin (Oflozacin	10mg	I don't Know	01/01/2020	Still Use	Remove
Floxin (Oflozacin	10mg	I don't Know	01/01/2020	Still Use	Remove
Floxin (Oflozacin	10mg	I don't Know	01/01/2020	Still Use	Remove

Add Medication

Family Mental and Physical Health

Has anyone in your family had any significant medical issues?

(Total text length 4, max allowed 1000)

Has anyone in your family had any significant behavioral issues?

(Total text length 4, max allowed 1000)

Which members of your family are you close to and why?

(Total text length 4, max allowed 1000)

Which members of your family were a source of hurt or pain to you and why?

(Total text length 4, max allowed 1000)

My Profile

Below are forms to provide us with information on your life, relationships, history, and more so we can provide the best treatment possible.

Patient Identity

Gender Identity

Contact Details

Health Providers

Household Occupants

Reason for Therapy

Partnership / Marital Relationship(s)

Medical History

Family Mental and Physical Health