Download Health History - Comprehensive Psychological Care

Patient’s Name:__________________________________________________________________ Today’s Date:___________________________
ADULT HEALTH HISTORY
Your answers will help better understand your medical history and identify possible contributors to your mental health problems. If you
are uncomfortable with any question, do not answer it. If you cannot remember specific details, give approximate answer.
Date of birth: ____________Age: _____ Height: _________ Weight: __________ Eye Color: ____________ Hair Color:____________
Date of last medical exam: ____________ Primary Physician’s Name, City, Phone Number:___________________________________
Highest level of education: ____________ Glasses: ________ Hearing Aids: __________
Handedness: Right Left Ambidextrous
How would you rate your general health currently? __ Excellent __ Good __ Fair __ Poor
SYMPTOMS: Please Check Symptoms You CURRENTLY HAVE OR HAD IN THE PAST YEAR
GENERAL
Loss of sleep
Low mood
Weight loss/gain
Headache
Nervousness
Anxiety
Panic attacks
Stress reaction
Fatigue easily
Low energy
Hyperactivity
Dizziness/fainting
Fever
Sweats
Forgetfulness
Tearfulness
Anger
Memory loss
Cold/heat
Intolerance
Hair loss
Other ______________
CARDIOVASCULAR
Chest discomfort
Chest pain
Palpitations
Irregular heart beat
Blood pressure H/L
Other ______________
HEALTH HABITS:
RESPIRATORY
Cough/wheeze
Difficulty breathing
Nose congestion
Chest congestion
Other ______________
EAR/NOSE/THROAT
Difficulty hearing
Ringing in ears
Allergies
Difficult swallowing
Other ______________
MUSCULO-SKELETAL
Muscle pain/tension
Pain/Weakness in:
Joints
Base of skull
Neck
Shoulder R/L
Back:
Upper R/L
Mid R/L
Lower R/L
Hip R/L
Thigh R/L
Knee R/L
Ankle R/L
Foot R/L
Other: ______________
GASTROINTESTINAL
Poor appetite
Overeating
Eating disorder
Heartburn/reflux
Nausea/Indigestion
Vomiting
Bowel problems
Excessive thirst
Bloating
Flatulence
Other ______________
EYES
Vision difficulties
Blurred vision
Visual flashes
Visual halos
Other ______________
Circle all that apply
Caffeine
Tobacco, cigarette
coffee/tea/soda
smoke/chew/snuff
Alcohol
beer/wine/liquor
Marijuana/
cannabis/THC
Medical use Rx
Joint/pipe/bong/
baked/brewed
Other recreational drugs (list)
Physical exercise
Diet
Excellent
GENITOURINARY
Urination difficulty:
Frequent
Painful
Blood in urine
Leaking urine
Other: ______________
Past Amount
___ beverages/day
___ packs/day
___ # years
__ beverages/week
__ # years
__ Rarely
__ Occasionally
__ Regularly
Describe amounts
__ # years
__ Occasionally
__ Regularly
Good
SEXUAL FUNCTIONING
Identity concerns
Low libido
High libido
Arousal difficulty
Orgasm difficulty
Sexual addiction
Painful intercourse
Fetish
Other ______________
MALE REPRODUCTIVE
Hormonal problems
Erectile dysfunction
Testicular problems
Low sperm count
Ejaculation concerns
Lump: breast/penis
Andropause
Other: ______________
FEMALE
REPRODUCTIVE
Hormonal problems
PMS
Pre-menopausal
Post-menopausal
Breast Concerns
Pregnancy concerns
Miscarriage
Other: ______________
Present Amount
Problems with this?
___ beverages/day
___ packs/day
___ # years
__ beverages/week
__ Rarely
__ Occasionally
__ Regularly
Describe use
__ # years
__ Occasionally
__ Regularly
Fair
Poor
CURRENT MEDICATIONS: Prescription and non-prescription medicines, home remedies, birth control pills, etc.
Comprehensive Psychological CARE
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Patient’s Name:__________________________________________________________________ Today’s Date:___________________________
CONDITIONS: Please check conditions you have now or had in the past and indicate date of diagnosis next to it
o
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Acid Reflux
Acne
Alcoholism
Allergies
Anemia
Anxiety
Appendicitis
Attention
Deficit Disorder
Alzheimer’s
disease
Anorexia
Arthritis
Asperger’s
Syndrome
Asthma
Autism
Autoimmune
disorder
Avoidant
Personality
Bedwetting
Bipolar
Disorder
Bladder
problems
Bleeding
disorder
Blood sugar
problems
Bone fracture
Borderline
Personality
Brain disease
Brain injury
Brain tumor
Breast cancer
Breast lump
Bronchitis
Bulimia
Burns
Bursitis
Cancer
____________
Carpal Tunnel
Cataracts
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Celiac disease
Chicken pox
Cholesterol
Chronic pain
Codependent
Personality
COPD
Colon
problems
Congestive
Heart Failure
Crohn’s
disease
Deep vein
thrombosis
Dependent
Personality
Depression
Diabetes
Disability (type)
Drug Abuse
Dyslexia
Elective
surgery
Endometriosis
Epilepsy
Erectile
Dysfunction
Fibromyalgia
Genetic
disorder
Gynecological
problems
Headache
Hearing loss
Heart attack
Heart disease
Hemorrhage
Hepatitis
Hernia
Herniated disc
Herpes
HIV/AIDS
Hormone
imbalance
Infertility
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Irritable Bowel
Kidney disease
Learning
Disability
Liver disease
Lupus
Measles
Menopause
Mental illness
Migraine
Miscarriage
Mononucleosis
Mood disorder
Multiple
Personality
Multiple
Sclerosis
Mumps
Narcissistic
Personality
Obesity
ObsessiveCompulsive
Orthopedic
difficulties
Osteoporosis
Pacemaker
Panic attack
Paranoid
Personality
Parkinson’s
disease
Phobias
Polio
Pneumonia
Posttraumatic
Stress Disorder
Prematurity
PMS
Prostate
problems
Prostate
problems
Psoriasis
Restless Leg
Syndrome
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Rosacea
Scars
Sciatica
Schizoid
Personality
Schizophrenia
Seizures
Sexually
Transmitted
Disease
Sleep disorder
Sleep apnea
Smallpox
Snoring
Social Anxiety
Stomach
problems
Suicide attempt
(# ____)
Surgical
termination of
pregnancy
Testicular
problems
Thyroid
problems
Tuberculosis
Ulcers
Urinary tract
infection
Varicose veins
Vertigo
Other
Conditions:
(List)
____________
_________
____________
_________
____________
_________
____________
_________
SURGICAL/HOSPITALIZATI0N HISTORY: Please list all serious illnesses, injuries, surgeries/procedures:
Illness/Injury
Surgery/Procedure
Hospitalized
Residual effects/problems
Yes No
Yes No
Yes No
Yes No
Yes No
PREGNANCY HISTORY: Please Note Outcome (live birth, miscarriage, surgical termination, etc)
Year
Outcome
Complications if any
Year
Comprehensive Psychological CARE
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Patient’s Name:__________________________________________________________________ Today’s Date:___________________________
PSYCHIATRIC HISTORY: Please note past history of mental health difficulties including Depression, Anxiety,
Bipolar Disorder, Personality Disorder, or other mental health diagnoses
Mental Health Issue
Age(s) when
identified
Duration
Treatment (psychotherapy,
medication, hospitalized, etc)
Are you currently experiencing suicidal thoughts?
Yes
Have you experienced suicidal attempts in the past?
Yes
Is violence or abuse at home a concern for you?
Yes
Have you ever been abused?
Yes
Have you been abusive toward others?
Yes
Do you have difficulty controlling your anger?
Yes
Do you have possession of, or access to, lethal weapons? Yes
Outcome, current status
No
If yes, do you have a plan? ____________________________
No
No
No
__Physical __Sexual __Emotional
No
__Physical __Sexual __Emotional
No Sometimes
No
FAMILY MEDICAL HISTORY: Please fill in health information about your family of origin (blood relatives)
Relation
Mother:
Father:
Brothers
Age
Indicate if
half-sibling
Current State of Health
(good, fair, poor), or
cause of death
Medical Problems
(Past and present)
History of Mental Health
Problems (Past/present)
Addiction
History
---------------------------------
Sisters
Is there anything else you feel is important for Comprehensive Psychological CARE to know about you or about
your concerns regarding your physical or mental health? If so, please describe:
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Comprehensive Psychological CARE
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