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Medical Information Name_____________________________________Soc. Sec. #_____________________Date______________ What is the reason you are seeking help at this time:________________________________________________ __________________________________________________________________________________________ Please check the items below which apply to you in the past six months _________ Change of Appetite __________ Loss of weight __________Weight Gain __________ Binge or purge __________ Worried about your weight __________ Trouble sleeping __________ High energy __________ Low energy __________ Restless/difficulty sitting still __________ Anxious or nervous __________ Loss of interest __________ Feel like mind playing tricks __________Worried about your appearance __________ Forgetfulness or memory problems __________ Anger __________ Verbal fighting __________ Physical fighting __________ Sexual problems __________ Difficulty concentrating __________ Racing thoughts __________ Sad or depressed __________ Crying spells __________ Thoughts of suicide __________ Self hurt/harm Have you ever had counseling/therapy or medication for any of the above?________Yes________ No If “Yes”, where, when, and from whom?_________________________________________________________ When did you last have a complete physical exam?_________________________________________________ Who is your primary care physician?____________________________________________________________ How do you rate your overall health? __________Excellent__________Good__________Fair__________Poor What is your main concern about your health?_____________________________________________________ Any other medical problems? If “Yes”, please describe._____________________________________________ Please complete the following regarding your current medication: Name of Medication/Herbs Prescription When prescribed Amt. Daily Reason Yes/No [Over] Medical info/Forms Do you have any allergies? If “Yes” please describe.______________________________________________ ________________________________________________________________________________________ Do you currently use illicit drugs? __________Yes__________ No Have you ever abused prescription or illicit drugs? __________Yes__________ No Do you drink alcohol? __________Yes__________ No How many times per week?__________________________________________________________________ On an average, how many drinks per time?______________________________________________________ Do you use nicotine? Yes No. How much ?_____ Do you use caffeine? Yes No How Much ?______ Have you ever: Thought you should cut down on your drinking or drug use? ___Yes ___ No Been annoyed when others have asked you about your drinking or drug use? ___Yes ___ No Felt guilty about how much you drink or use? ___Yes ___ No Had a drink/used to get going or to treat a hangover? ___Yes ___ No Has anyone complained about your drinking/using? ___Yes ___ No Gotten into trouble with the law, family members, friends when you drink/use? ___Yes ___ No Do you usually get into trouble when you drink/use? ___Yes ___ No Do you gamble? __________Yes ___________No How many times per month?_______________________________________________________________________ What percent of your monthly income do you spend per month on gambling?________________________________ Have you ever felt the need to bet more & more money?_______________________________________________ Have you ever had to lie to people important to you about the extent of your gambling?_________________________ Please check the items below which describe medical symptoms you have had in the past 12 months. ______persistent cough ______thyroid disease ______abnormal heartbeat ______severe/persistent headaches ______seizures ______muscle weakness ______joint/aches/pains ______kidney infection/disease ______urinary infection ______stomach/abdominal pains ______change in vision/trouble with eyes ______change in sense of smell ______pain in mouth or trouble swallowing ______speech problem ______pain/lump/drainage from breasts ______shortness of breath ______high blood pressure ______balance problems/falling ______loss of consciousness ______numbness or weakness of limbs/body ______muscle pain ______bruise easily ______trouble urinating ______liver disease ______vomiting ______changing in hearing/trouble with ears ______feeling clumsy or dropping things. ______sore/swollen neck/glands ______voice problems Signature_________________________________________________________________________________________ Signature of parent if completed on behalf of a minor child_________________________________________________ Therapist signature______________________________________ Date reviewed______________________________ Referred for physical exam? ____________ Yes ____________No To whom_________________________________________ Client willing to accept referral _______ Yes ______ No Referred for psychiatric evaluation? ______Yes ______No To whom_________________________________________ Client willing to accept referral _______ Yes ______ No
