Behavioral Health History Form

Mid-Delta Health Systems, Inc.

Registration Form
Today's Date

MonthDayYear
Date
PATIENT INFORMATION

Thank you for choosing us! As a Federally Qualified Health Center, and in order to better serve you, we request you provide us with the following information.
Patient Name

First NameLast Name
Email
example@example.com
Date of Birth

MonthDayYear
Date
Age
Have you filled out the New Patient Form?

YesNo
How did you hear about this clinic?
Describe briefly your present symptoms
Please list the names of other practitioners you have seen for this problem
Psychiatric Hospitalizations (include where, when, and for what reason)
Have you ever had ECT?

YesNo
Have you had psychotherapy?

YesNo
Substance Use Rehabilitation or Detox?

YesNo
If yes, dates:

CURRENT MEDICATIONS
Are you allergic to any medications?

YesNo

Please list any medications that you are CURRENTLY TAKING. Include non-prescription medications & vitamins or supplements (if using a smart phone, you may have to turn to landscape view):

Rows	Name of Drug	Dose (strength & number per day)	How long have you been taking
1
2
3
4
5
6
7
8
9
10

Please list any medications that you have PREVIOUSLY TAKEN. Include non-prescription medications & vitamins or supplements (if using a smart phone, you may have to turn to landscape view):

Rows	Name of Drug	Dose (strength & number per day)	How long have you been taking	Adverse effects
1
2
3
4
5
6
7
8
9
10

FAMILY HISTORY
FATHER: Age if living or age at death
FATHER: Health & Psychiatric
FATHER: Cause of death (if deceased)
MOTHER: Age if living or age at death
MOTHER: Health & Psychiatric
MOTHER: Cause of death (if deceased)
SIBLINGS: Age if living or age at death
SIBLINGS: Health & Psychiatric
SIBLINGS: Cause of death (if deceased)
CHILDREN: Age if living or age at death
CHILDREN: Health & Psychiatric
CHILDREN: Cause of death (if deceased)
Extended family psychiatric problems, past & present.
Please specify maternal or paternal

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Mid-Delta Health Systems, Inc.

PATIENT INFORMATION

CURRENT MEDICATIONS

HEALTH HISTORY

PERSONAL HISTORY

FAMILY HISTORY

IN THE PAST MONTH, HAVE YOU HAD ANY OF THE FOLLOWING PROBLEMS

WOMEN'S REPRODUCTIVE HISTORY

SUBSTANCE USE