Follow the steps to fill out the CASE PRESENTATION TEMPLATE.

1. Press the ‘Get Form’ button to access the form and open it for editing.
2. Start by entering the date in the designated field.
3. Fill in your name along with your location.
4. In the section asking for your goal for this consultation, clearly articulate the purpose of your submission.
5. Provide the patient's name and date of birth in the respective fields.
6. Check the appropriate box to indicate whether the patient is a new or follow-up patient.
7. Select the patient's gender by marking the corresponding box.
8. Input the patient's occupation in the space provided.
9. Indicate the alcohol use status, and if applicable, specify the quantity consumed.
10. Note whether the patient is a current smoker, indicating yes or no.
11. Document any illicit drug use, specifying the names and frequency as needed.
12. Summarize the current and past medical history thoroughly in the available space.
13. Detail the current and past behavioral and medical therapies the patient has undergone.
14. Outline any behavioral health history, including hospitalizations, in the specified area.
15. Describe any involvement the patient may have had with the criminal justice system.
16. List medications the patient is currently taking, if any.
17. Provide pertinent family history that could impact the patient’s care.
18. Include any other relevant history such as laboratory or imaging results.
19. After completing the form, save the changes and prepare to submit.
20. Lastly, fax the completed form to (775) 327-5112 as per the instructions.

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