(AFFILIATED WITH BEHAVIORAL COUNSELING SERVICES, LLC)
R6-5-7455(1, 3, 4)
THIS RECORD SHOULD BE KEPT ON FILE AT THE FACILITY
Client"s past medical history upon arrival
Did you receive a copy of youth"s Immunization Records (If yes, please attach)
List any illnesses or serious injuries
Any Known Allergies?
Any Adverse Drug Reactions?
Explain Client"s past medical history:
Please list any history of alcohol and/or substance abuse habits. Include any treatments:
Any Documentation (Prescriptions) of medication(s) received with child at time of admisssion
COMPLETED BY (STAFF NAME)
Should be Empty: