Patient Registration |
|
|
Name: Veronica
Welsh
Gender: X Female Male |
Social Security: 036-31-5413
Profession: Music composer/ D.J. |
Date of Birth: 3/1/74 |
How did you here of us? Time
Out article
Have you or any of your family members been treated at the Tear Stopping
Lab in the past? No
If yes, please specify
name and relation to you |
General Medical Information
Present Medication: none
Do you smoke: X Yes No
|
Allergies
to medications: none
Number of years: 10
|
How much: pack/day
|
Do you regularly
drink alcohol? X Yes No
Do you drink coffee? X Yes No
Are under a lot of pressure at work: X Yes No
Have you ever consumed psychedelic drugs? X Yes No |
How many drinks per day: 5
How many cups per day: 3
Please describe: in life, not work
How many times: 3 (mushrooms) |
Personal Tear Information
How often do you cry? Never
For how long do you cry? _N/A
What helps you stop crying? _N/A |
What causes your crying?
a. Love (or lack of love)
b. The loss of a loved one.
c. General emotional abuse.
d. Financial hardship or job related stress.
e. Other (please specify) __________________ |
