PSYCHIATRIC DIAGNOSIS ABUSE REPORT FORM

PSYCHIATRIC DIAGNOSIS ABUSE REPORT FORM
Protect Yourself Against Misdiagnosis and Abuse

NAME OF DOCTOR SEEN :

NAME OF HOSPITAL, IF ANY:

ADDRESS/CONTACT INFORMATION :

DATE(S) SEEN :

REASON FOR VISIT :

SYMPTOMS CONVEYED TO DOCTOR :

HOW LONG WAS THE CONSULTATION? :

IF A CHEMICAL IMBALANCE WAS GIVEN AS PART OF THE DIAGNOSIS, DID YOU ASK THE DOCTOR FOR A TEST TO SUBSTANTIATE THIS? IF SO, WHAT DID HE SAY?:

WHAT TREATMENT WAS PRESCRIBED? (If psychiatric drug, name the drug, the dose and the reason this was recommended):

DID THE DOCTOR ADVISE THAT THE DRUG IS APPROVED FOR THE USE IN THE TREATMENT OF DIAGNOSIS GIVEN YOU?:

DID YOU EXPERIENCE ANY ADVERSE REACTION FROM THE TREATMENT? (Provide Details):

WAS THERE ANY IMMEDIATE OR LONGER TERM PHYSICAL OR MENTAL CONDITION OR DAMAGE AS ARESULT OF THE TREATMENT? (Provide details):

DID YOU LATER ESTABLISH THAT THERE WAS A MEDICAL CONDITION THE PSYCHIATRIST OR DOCTOR DID NOT DIAGNOSE OR IDENTIFY BEFORE GIVING THE PSYCHIATRIC DIAGNOSIS? If so, please provide specifics and if that condition was diagnosed by another physician who conducted appropriate tests.:

WAS YOUR INSURANCE COMPANY BILLED FOR THE TREATMENT FOR THE EARLIER MISDIAGNOSIS?(Please give specifics, including insurance company and amount billed?:

SIGNED :

DATE :

YOUR NAME :

ADDRESS :

PHONE :

EMAIL : *

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