B. Medical History

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NOTE: If the client is 18 years of age or older, the client is the only person permitted to complete and sign this form. If the client is under the age of 18, the parent or guardian must complete and sign this form.

Legal Name

First NameMiddle NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Date of Birth

MonthDayYear

Preferred Name

Today's Date

Date

Form Being Completed By:

Relationship to Client:

Presenting Problem

What are the 2-3 primary reasons you are seeking counseling/therapy?

How long ago did you begin to be troubled by this problem?

List three (3) goals you would like to accomplish by attending counseling:

Is this the first time you've seen a therapist/counselor for these issues?

Please explain how previous counseling helped and/or didn't help you with these issues.

Symptoms Checklist

Check All Current Problems

Depressed Mood/Sad (as evidenced by)

Nutritional/Eating Pattern Changes/Disorders (as evidenced by)

Pain Management (as evidenced by)

Grief Issues (as evidenced by)

Other

Traumatic Stress (as evidenced by)

Anger/Aggression (as evidenced by)

Oppositional Behaviors (as evidenced by)

Anxiety (as evidenced by)

Inattention (as evidenced by)

Addictive Behaviors (as evidenced by)

Sleep Problems (as evidenced by)

Stressors

Past Diagnosis

Please explain the diagnosis you received.

Who was diagnosed? Name
When was the diagnosis? Date

Family history of mental health?

Diagnoses? Name

Past trauma history?

Past traumatic experience(s)

When did the incident(s) occur? Name

Psychiatric hospitalizations?

Spiritual/Religious Beliefs?

What is important in a therapeutic relationship?

Living Situation

My Home

Please list household information (use "+" to add more)

Please list additional household information (use "+" to add more)

Education, Employment, and Military Information

Education History

College

Degree/Major

Other Degrees Completed:

History of Learning Difficulties (including performance/behavioral problems due to AUD use)

Explain

Special Communication Needs

Please Explain

Employment or School (check all that apply)

Date Last Worked Or Attended?

Date

If employed, name of employer

Current job title

Job Performance History

Number of jobs in past 5 years

Comments

(include performance/behavioral problems due to alcohol or drug use)

Attendance

Are you satisfied with your job?

Performance

Are you experiencing financial problems?

(If not currently employed) Do you want to work?

COMMENTS ON PAST OR CURRENT EMPLOYMENT/EDUCATION SKILLS/INTEREST

(Include information relating to past or current employment/education skills and interest

Military History

PLEASE DESCRIBE BRANCH OF SERVICE, ANY PERTINENT DUTIES, AND ANY TRAUMA EXPERIENCED DURING SERVICE, AS APPLICABLE

Type of Discharge?

If other than General/Honorable

Legal History

Legal Guardians/Custodian - Name, Address, and Phone Number

History or Legal Charges

Yes, please explain

Explain

List and Date of Most recent charges

Convictions?

Please Explain Convictions

Name and Phone Number of Probation/Parole Officer (If applicable)

Civil Proceedings?

Domestic Relations Court Problems

*i.e., custody, protective services, restraining order)

Juvenile Court Involvement (Related to child abuse, neglect, or dependency)

Currently, Please Explain

Past, Please Explain

Child Protective Services involvement with family

Name of Children's Protective services Caseworker(s) Assigned to Family (If applicable)

Other

Adult Health History Questionnaire

Have you had any of the following health problems?

Which of these were in the past?

Which of these are you dealing with now?

What treatments were received and date(s) (medication/5-3-2009)

Current Medication Information

(medical and psychiatric prescription/OTC/herbal)

Medications

Please list your current medications

Contact information for Primary Care Physician

Primary Care Physician contact information:

Other Prescribing Physician(s)

Past Psychiatric Medications

IF No Past of Psychiatric Medications

Have you had medical hospitalization/surgical procedures in the last 3 years?

Other

Allergies/Drug Sensitivities

Food (specify)

Medicine (specify)

Other (Specify)

Pregnancy History

Currently Pregnant?

Any Significant Pregnancy History?

Explain Pregnancy Related Issues

Medical Information

Last Physical Examination

Have you had any of the following symptoms in the past 60 days?

Immunizations - have you had or been immunized for the following diseases? (please check all that apply)

Immunizations within the past year

Has client's weight changed in the past year?

By how much ( + or - ) and how often

Nutritional Screening

If No Problem

Eating

Drinking

Appetite

Explain any issues:

Pain Screening

Does pain currently interfere with your activities?

Please indicate the source of pain

CAGE-AID Questionnaire: Substance use screening tool

When thinking about drug and alcohol use in the last 90 days, include illegal drug use.

Rows	NO (0) points each	YES (1) point each
C. Have you ever felt that you ought to Cut down on your drinking or drug use?
A. Have people Annoyed you by criticizing your drinking or drug use?
G. Have you ever felt bad or Guilty about your drinking or drug use?
E. Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover (Eye opener)?

CAGE-AID Score

Substance Use History / Current Use

Which of the Following have you used?

Beer

Wine

Liquor

Heroin

Barbiturates

Amphetamines

Crack

LSD

Marijuana / Hashish

Inhalants

PCP

MDMA (XTC)

Prescription drugs off the street

Non-Prescription drugs by injection

Cocaine

Caffeine

Nicotine

Is this for a child?

Custodial Parent

Pertinent Developmental Issues

Mothers Pregnancy History (include prenatal exposure to alcohol, tobacco, and other drugs)

Please Explain

Infancy (Ages 0 - 1)

Please Explain

Preschool (Ages 2 -4)

Please Explain

Childhood (Ages 5 - 12)

Please Explain

Adolescent (Ages 13 - 17)

Please Explain

Family Environment/Relationships

Parent-Child (Client) Relationship(s):

Comment on Parent-Child Relationship(s): (could include parent-child conflict, parent supervision and monitoring of child, cooperation between parents regarding child rearing, parent positive activities with child, parent satisfaction with relationship, child satisfaction with relationship(s))

Sibling-Child (Client) Relationship(s)

Comment on Sibling-Child Relationship(s): (could include sibling-child conflict, positive activities with child, sibling satisfaction with relationship, child satisfaction with relationship(s))

Parent Marital or Couples Relationship(s):

Comment on Parent Marital or Couples Relationship(s): (could include marital or couples conflict, marital or couples satisfaction with relationship(s))

School Functioning

Regular Education Classes? (No Special Services)

Any School Related Concerns:

Print Name Of Person Completing This Questionnaire

Date

Signature

Medical-Social History