HEALTH INFORMATION FORM
Please complete the SECURE on-line form below.
Please read each of the following and initial in the box directly below indicating you knowledge and understanding
Name
*
First Name
Last Name
Todays Date
*
-
Month
-
Day
Year
Date
Reason for entering into services?
Please check any symptoms that describe how you feel, think, or behave currently or within the last 3 months:
Abdominal pain
Aggressive/abusive towards other
Agitation
Attempts to harm self
Avoidance of public places
Back pain
Change in ability to walk
Chest pain
Chest tightness
Chronic sadness
Confused/worried about sexual behavior
Constipation
Crying episodes
Diarrhea
Difficulty at work/school
Difficulty completing tasks
Difficulty concentrating
Difficulty focusing
Difficulty functioning socially
Difficulty making decisions
Difficulty waiting your turn
Dizziness
Easily startled
Excessive gambling
Excessive spending
Excessive worry
Fainting
Fear of dying
Fear of leaving home
Fear of loss of control
Fearfulness
Frequent forgetfulness
Frustration
Hard to stay with job very long
Hopelessness
Intrusive thoughts of bad memories
Irritability
Legal problems
Change in eating habits: stress eating/loss of appetite
Low energy/fatigue
Marital conflict
Memory problems
Multiple sexual partners
Muscle stiffness
Muscle weakness
Nausea/Vomiting
Neck Pain
Nightmares
Not well organized
Overeating
Panic attacks
Physical abuse
Pounding heart/palpitations
Problems with co-workers
Racing thoughts
Reduced interest in activities
Re-living bad experiences
Restlessness
School problems
Seeing/hearing things others don’t
Seizures
Sexual abuse/rape (recent or past)
Shortness of breath
Sleep problems
Snoring
Staying up for days without sleep
Taking on too many tasks
Taking on too many tasks
Thoughts of physically hurting others
Thoughts of suicide/homicide
Trembling/shaking
Vision changes
Withdraw from others
Self-Injury without suicide attempt (i.e. cutting, hair pulling, and banging of head etc.)
Please describe why you are seeking help at this time
*
Has any member of your family been hospitalized for mental health concerns?
Yes
No
If yes, please list who, when and for what reason
Do/did you have any family members who have/had problems with drinking alcohol or using drugs?
Yes
No
If yes, please list who, when and if it is still a problem
Has any member of your family attempted/committed suicide?
Yes
No
If yes, Please list who, when, and what happened
What is your best memory about your family when growing up?
*
If you could change anything about your family situation right now, what would it be?
*
Have you ever seen a counselor, psychologist, psychiatrist, or other mental health professional for any mental health or drug/alcohol concerns?
Yes
No
If yes, please list who, when and why
Have you ever been hospitalized for mental health or drug/alcohol concerns?
Yes
No
__________________________________________ If yes, please list when and for what reason
Do you have thoughts of harming yourself?
Yes
No
If so, how often does this happen?
Have you ever tried to harm yourself?
*
Yes
No
If so, when did this happen?
Did you receive medical help at the time?
Yes
No
Current Medications. If none, please leave blank.
(Please include prescription, over the counter, herbs, vitamins, and other remedies)
Medication 1
Dosage/when taken
Reason taking
Prescribing Doctor
Medication 2
Dosage/when taken
Reason taking
Prescribing Doctor
Medication 3
Dosage/when taken
Reason taking
Prescribing Doctor
Medication 4
Dosage/when taken
Reason taking
Prescribing Doctor
Medication 5
Dosage/when taken
Reason taking
Prescribing Doctor
Medication 6
Dosage/when taken
Reason taking
Prescribing Doctor
Medication 7
Dosage/when taken
Reason taking
Prescribing Doctor
Medication 8
Dosage/when taken
Reason taking
Prescribing Doctor
Medication 9
Dosage/when taken
Reason taking
Prescribing Doctor
Medication 10
Dosage/when taken
Reason taking
Prescribing Doctor
Medication 11
Dosage/when taken
Reason taking
Prescribing Doctor
Medication 12
Dosage/when taken
Reason taking
Prescribing Doctor
Medication 13
Dosage/when taken
Reason taking
Prescribing Doctor
Allergies to medications
*
Please list any current medical problems or concerns
*
Please list any past serious illnesses, surgeries or health concerns
*
Exercise and Physical Recreational Activity
Type of activity & How often
*
Would you describe yourself as physically active?
*
Do you currently have a primary care physician? If so, please list his/her name:
*
Are you currently under the care of any other physicians? If so, please list names:
*
Use of substances (on average) If none, please leave blank.
Alcohol?
*
Yes
No
Current Amount. (Number per day)
Current Amount. (Number per week)
Current Amount. (Number per episode)
Current Amount. (Type of alcohol) (Beer, Whiskies, Wine, Etc)
Current Amount. (Size of drinks) (Can, Tallboy, Shots, Etc.)
Most used in Past. (Number per day)
Most used in Past. (Number per week)
Most used in Past. (Number per episode)
Most used in Past. (Type of alcohol) (Beer, Whiskies, Wine, Etc)
Most used in Past. (Size of drinks) (Can, Tallboy, Shots, Etc.)
Tobacco
*
Yes
No
Current Amount. (Cigarettes per day)
Current Amount. (Cigars per day)
Current Amount. (Smokeless cans per day)
Most used in Past. (Cigarettes per day)
Most used in Past. (Cigars per day)
Most used in Past. (Smokeless cans per day)
Caffeine(tea, coffee, soda)
*
Yes
No
Current Amount. (Servings per day)
Most used in Past. (Servings per day)
Marijuana
*
Yes
No
Current Amount. (per day)
Current Amount. (per week)
Most used in Past. (per day)
Most used in Past. (per week)
Cocaine
*
Yes
No
Current Amount. (times per day)
Current Amount. (times per week)
Most used in Past. (times per day)
Most used in Past. (times per week)
Pills
*
Yes
No
Current Amount. (pills/doses per day)
Current Amount. (pills/doses per week)
Current Amount. (Type of pills. (pain pill, Xanax etc.)
Most used in Past. (pills/doses per day)
Most used in Past. (pills/doses per week)
Most used in Past. (Type of pills. (pain pill, Xanax etc.)
Use of the below substances (on average) If none, please select None.
*
Cocaine
Methamphetamines
Heroin
Molly
Hallucinogens - Mushrooms/Mushroom tea, LSD, etc.
Ecstasy
Synthetic drugs i.e. bath salts, spice etc.
None of the Above
Other
If you selected OTHER, please name
If you need to list more than one, please list them
Current Amount. (How often used. Daily, Weekly, Occasional?)
Current Amount. (Amount used?)
Most used in Past. (How often used. Daily, Weekly, Occasional?)
Most used in Past. (Amount used?)
Marital status
*
Have you ever been married/partnered?
*
How many times?
*
Longest relationship?
*
Reason for ending marriages/partnerships?
*
Number of Children?
*
Do you have custody?
*
If no, who has custody?
Education?
*
Difficulties with education?
*
Living arrangements?
*
Employment?
*
Military Service? (What Branch?)
Military Service? (Active duty/Discharged/Retired?)
If discharged type of discharge?
MOS? (Job in Military)
Combat Experience?
Yes
No
Military sexual trauma?
Yes
No
Are you currently eligible for or receiving VA Benefits/Treatment?
Yes
No
*If you need records sent to the VA please provide a release of information and specify which VA facility/department records need to be sent to:
Submit
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