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Name *
E-mail Address *
Addiction/Alcoholism Treatment Facilities Attended: *
Hospitalization Due to Drugs/Alcohol: *
List Medications you are presently taking: (include over the counter medications) *
Have you seen a Dr. in the last year to refill medication? Give Doctor's name, location and medication: *
Medical History - do you have any history of:	Chronic bronchitis
	Heart problems
	Stomach or bowel problems
	Pancreatitis
	Epilipsy or other seizures
	IV Drug Use
	Asthma
	High blood pressure
	Liver problems (inc. Hepatitis B/C)
	HIV/AIDS
	Psychiatric Treatment
	Allergies
Any other diseases or medical concerns not listed above: *
Past or present mental health issues such as depression, anxiety, phobias, etc. *
Suicide attempts: *
T.B. Screening: A recent (last 6 months) Mantoux skin test (and possibly a Chest X-Ray) will be required. List the: Location, Date and Results of your most recent test or list the date of your upcoming appointment for the test: *
Chest X-Ray: List the: Location, Date, and Results, or list the date of the upcoming appointment of your x-ray if required (if a negative TB test was found an x-ray may not be required. If so type N/R): *

I have read and agree to the Privacy Policy *

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By submitting this form I certify that all the information that I have given is complete and accurate.  I understand the importance of this information to my own health and the health of the residents, staff and visitors to Jellinek House.