-- Updated October 27, 2012 --
Please note: Although Dr. Sterling does not inquire about health insurance,
it is important that you understand that he has opted out of Medicare, Medicaid and all federal and state health programs.
Any prescriptions that he writes for you cannot be paid for by any federal or state program.

If you wish to fill this form out before arriving at Dr. Sterling's office, you may print it out and write in the requested information.

If you wish to paste this form into an e-mail so that you can fill it out there and e-mail it to Dr. Sterling, please click here to get instructions about how to copy and paste this form in an e-mail. If you wish to send this information to Dr. Sterling by e-mail, we recommend that you send it from a secure e-mail address. Go to our E-Mail page to get information about secure e-mail. Please remember that all information you send to Dr.  Sterling is kept strictly confidential.

For purchasers of ongoing E-Mail, Internet Chat, or Telephone Counseling services, if you do not wish to send this information by e-mail, you can schedule a Short Telephone Consultation with Dr. Sterling at which time he can take this information from you by phone.

Basic Information

Full Name (First Middle Last):

Date of Birth:

Social Security Number:

Gender (Male or Female):

Marital Status (Married, Divorced, Never Married):

Number of Children:

Ages of Children:

Home Address (Street, City, State, Zip Code):

Home Phone Number (Include Area Code):

Cellular Phone Number (Include Area Code):

Education (high school, college degree(s), postgraduate degree(s), professional certifications):


Work Address (Street, City, State, Zip Code):

Work Phone Number (Include Area Code):

Primary Race or Ethnic Group:

Emergency Contact Information

Full Name of Person to Contact in Case of Emergency:

Relationship To You (spouse, child, parent, friend, etc.):

Home Phone Number of Emergency Contact (Include Area Code):

Work Phone Number of Emergency Contact (Include Area Code):

Cellular Phone Number of Emergency Contact (Include Area Code):

Primary Doctor Information

Full Name of Current Primary Doctor:

Office Address of Primary Doctor:

Office Phone Number of Primary Doctor (Include Area Code):

Other Doctor Information

List All Other Doctors You Have Seen in Last Two Years and the Reasons for Consulting Them:


List All Medication or Drug Allergies:

List All Other Allergies (milk, chemicals, dust, etc.):

Recent Counseling and Mental Health Care

List All Counselors or Mental Health Care Professionals You Have Seen in the Last Two Years:

Current Health Conditions



Blood Pressure (if known):

How Much Exercise Per Week do you Get?:

Do You Smoke Cigarettes?:

Did You Smoke Cigarettes?:

How Much Alcohol (beer, wine, hard liquor) do You Drink Per Week?:

List All Current Health Problems (high blood pressure, low blood pressure, diabetes, heart conditions, etc.):

Current Medications

List The Names of All Current Medications That You Take:

Past Medications

List The Names of All Medications Prescribed or Taken in the Last Two Years:

Current Health Concerns

List All Symptoms That You Are Currently Concerned About (sleep loss, weight loss, weight gain, dizziness, breathing problems, depression, etc.):

Accidents and Injuries

List All Major Accidents and Injuries Including any Mild to Severe Concussions:


List All Major Surgeries You Have Had:

Past Medical and Mental Health Problems

List All Past Medical and Mental Health Problems and Illnesses:

Current and Past Legal or Financial Difficulties

Any Current or Past Problems with Breaking any Laws (yes or no)?:

Any Current or Past Gambling Problems (yes or no)?:

Any Current Uncontrolled Spending or Debt Problems (yes or no)?:

Current and Past Relationship Problems

Are You Too Angry or Violent in Relationships?:

Do You Experience Violence and Anger in Relationships?:

Are You Very Shy?:

Please List Any Other Relationship or Social Problems You Feel You Have: