MEDICAL HISTORY
ACHIEVING BETTER COPING SKILLS LLC R6-5-7455(1, 3, 4)
Client"s past medical history upon arrival
LOCATION
Please Select
ASHER HOUSE
SHOULDER'S HOUSE
YOUTH NAME
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Did you receive a copy of youth Immunization Records (If yes, please attach)
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Yes
No
List any illnesses or serious injuries
Any Surgeries?
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No
Yes (Please explain)
Any Known Allergies?
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No
Yes (Please explain)
Any Adverse Drug Reactions?
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No
Yes (Please explain)
Explain Client"s past medical history:
*
Please list any history of alcohol and/or substance abuse habits. Include any treatments:
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COMPLETED BY (STAFF NAME)
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Staff Signature
*
Submit
Should be Empty: