Rittenhouse Women's Wellness Center

Available Forms

A.) Internal Medicine Authorization to Release Healthcare Information A.) Internal Medicine Health History Form A.) Internal Medicine HIPAA : Notice of Privacy Practices A.) Patient Registration B.) Dermacenter Client Information and History C.) Nutrition 3 Day Food Diary C.) Nutrition History D.) Dr. Perilstein: Emotional Well-being Authorization to Release Protected Health Information D.) Dr. Perilstein: Emotional Wellbeing Consent for Treatment D.) Dr. Perilstein: Emotional Wellbeing Receipt of Privacy Information E.) Dr. Liggera's Patient Registration Form F.) Payment and Cancellation Policy G.) Email Agreement

E.) Dr. Liggera's Patient Registration Form

Last Name *

First Name *

Middle Initial

Name of Parent or Guardian if under 18 years old

Date of Birth *

Insurance Plan *

Insurance Member ID # *

Marital Status *

Please list any children and age

Address

City, State, Zip

Home Phone Number *

May we leave a message? *

Cell Phone Number/Other

May we leave a message

Email address *

May we email you? *

Referred By (If any)

Employer Name

Employer Address

Employer City, State and Zip

Job Title

Length of time at current position

Years of Education Completed

Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)? *

If yes, previous therapist/practioner

Name and Contact Information of Primary Care Practioner

Are you currently taking any prescription medication? *

If yes, please list

Have you ever been prescribed psychiatric medication? *

If yes, please list and provide with dates:

Who may we contact in case of an emergency? *

Name and Phone Number

GENERAL HEALTH AND MENTAL HEALTH INFORMATION

How would you rate your current physical health? *

Please list any specific health problems you are currently experiencing:

How would you rate your current sleeping habits *

Please list any specific sleep problems you are currently experiencing:

How many times per week do you generally exercise? *

What types of exercise do you participate in:

Please list any difficulties you experience with your appetite or eating patterns: *

Are you currently experiencing overwhelming sadness, grief or depression? *

If yes, approximately for how long?

Are you currently experiencing anxiety, panic attacks or have any phobias? *

If yes, when did you begin experiencing this?

Are you currently experiencing any chronic pain? *

If yes, please describe:

Do you drink alcohol more than once a week? *

How often do you engage in recreational drug use? *

Have you ever sustained a head injury? *

Have you ever been exposed to toxic chemicals? *

Are you currently in a romantic relationship? *

If yes, how long?

On a scale of 1-10, how would you rate your relationship?

What significant life changes or stressful events have you experienced recently: *

FAMILY MENTAL HEALTH INFORMATION

In the section below identify if there is a family history of any of the following. If yes, please indicate the family member's relationship to you in the space provided (Father, Grandmother, Uncle, etc...)

Alcohol/Substance Abuse *