Order Number First Name: * Last Name * Date * Phone Number * E-mail * Date of Birth * Social Security Number Family Status Single Girlfriend Boyfriend Married Divorced Widowed Children Gender * Male Female Height Weight Smoker? * Non-Smoker Smoker Are you a US Citizen yes no Do you speak English? yes no Religion/Faith Home Church Drugs of Choice * Method of Ingestion * How Often Date Last Used * Have you detoxed? * yes no Have you been through other programs? yes no if yes, how many? Name of last program you attended: Have you ever been to TLC before? yes no If yes, When? How did you hear about TLC? Are you currently collecting (check all that apply, write NONE if no): * Unemployment Disability SSI Other If other, Explain: Do you receive any other income (IRA, Pension, Savings/Checking account, 401K,ECT...) please list or write NONE if no Have you ever been arrested? yes no If yes, Please explain... Have you ever been arrested for arson? Yes No If yes, Explain: Have you ever been accused/convicted of child/sexual abuse? * yes no If yes, Explain: Any pending/open legal charges? * yes no If yes, Explain: Do you have any legal restrictions prohibiting you from leaving NY state or crossing any other state borders? * yes no Explain: Are you currently on probation or parole? * yes no Probation officers name and phone number State Please check all that apply: Tuberculosis Whooping Cough Asthma Head Lice Polio Hepatitis A Hepatitis B Hepatitis C Scarlet Fever Hay Fever Venereal Disease HIV Extreme Depression Heart Disease Heart Attack Diabetes Epilepsy Past Diseases Disabilities in the past year (check all that apply) 4+ Colds Yearly Frequent Leg Pains Dizziness Frequent Sties Frequent Sore Throat Poor Vision Dental Defects Heart Condition Bed Bugs Fainting Spells Abdominal Pains Frequent Urination Allergies Persistent Cough Speech difficulty Crippling Conditions Trauma Hearing Difficulty Tire Easily Shortness Of Breath Hernia (rupture) Ringworm Nose Bleeds Ringing in ears Seizures OTHER If OTHER , Explain: Any suicide attempts * yes no Dates: Tetanus shot within last 5 years yes no Food Allergies? yes no If yes, list foods: Latex Allergy? yes no Please list any current medications (name and Dosages): * Please list any other medical conditions or issues we should be aware of: * Name of primary DR: DR Phone number: Applicant Digital Signature: First name, Last name , Date *
