Joan B. Jablow, APMHNP 45 Byram Lake Road Mt. Kisco, New York (914)
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1 Joan B. Jablow, APMHNP 45 Byram Lake Road Mt. Kisco, New York (914) Personal Adult (18+) Client s name: Date: Gender: F M Date of birth: Age: Address: City: State: Zip: Phone (home): (work) ext: Please describe the issues you would like to discuss: Significant Relationships (please fill in any you consider significant, including those not listed, such as siblings or grandparents): Living Age Living with you Mother Father Spouse/Partner/Significant Other Child Marital Status (more than one answer may apply) Single Divorce in process Unmarried, living together Legally married Separated Divorced Total number of marriages:
2 Development Are there special, unusual, or traumatic circumstances that affected your development? Has there been a history of child abuse? If yes, which type (s)? Sexual Physical Verbal Social Relationships How do you generally get along with other people: (check all that apply) Affectionate Aggressive Avoidant Fight/argue often Follower Friendly Leader Outgoing Shy/withdrawn Submissive Other (specify) Sexual orientation: Cultural/Ethnic How important are spiritual matters to you? Not at all Some A lot Are you affiliated with a spiritual or religious group? Were you raised within a spiritual or religious group? Would you like your spiritual/religious beliefs incorporated into the counseling? Legal Are you involved in any active cases (traffic, civil, criminal)? Are you currently on probation or parole? 2
3 Education What is your highest level of education? High school / GED Some college Undergraduate degree Graduate degree Other: please describe Employment Currently employed? Employer: Job title: Military Military experience? Where: Branch: Combat experience? Discharge date: Leisure/Recreational Describe special areas of interest or hobbies (e.g., art, books, crafts, physical fitness, sports, outdoor activities, church activities, walking, exercising, diet/health, hunting, fishing, bowling, traveling, etc.) 3
4 Medical/Physical Health Please check which of the following you have had or currently have: AIDS Dizziness Nosebleeds Alcoholism Drug abuse Pneumonia Abdominal pain Epilepsy Rheumatic fever Abortion Ear infections Sexually transmitted diseases Allergies Eating problems Sleeping disorders Anemia Fainting Sore throat Appendicitis Fatigue Scarlet fever Arthritis Frequent urination Sinusitis Asthma Headaches Stroke Bronchitis Hearing problems Sexual problems Bedwetting Hepatitis Tonsillitis Cancer High blood pressure Tuberculosis Chest pain Kidney problems Thyroid problems Chronic pain Measles Vision problems Colds/coughs Mononucleosis Vomiting Constipations Mumps Whooping cough Dental problems Menstrual pain Other (please describe Diabetes Mononucleosis Diarrhea Nausea List any current health concerns not mentioned above: List any recent health or physical changes: Current prescribed medications Dose Current over-the-counter medications Dose Are you allergic to any medications or drugs? Last physical exam Last doctor s visit Last dental exam Date Reason Results 4
5 Most recent surgery Other surgery Upcoming surgery Family history of medical problems: Please check if there have been any recent changes in the following: Sleep patterns Eating patterns Behavior Energy level Physical activity level General disposition Weight Nervousness/tension Chemical Use History Alcohol Method of Frequency Age of Age of Used in last Used in last use and amount of use first use last use 48 hours 30 days Yes No Yes No Barbiturates Valium/Librium Cocaine/Crack Heroin/Opiates Marijuana PCP/LSD/Mescaline Inhalants Caffeine Nicotine Over the counter Prescription drugs Other drugs Substance of preference Substance Abuse Questions Describe when and where you typically use substances: Describe any changes in your use patterns: 5
6 How does it affect your life? Who or what has helped you in stopping or limiting your use? Does/has someone in your family have/had a problem with drugs or alcohol? Have you had withdrawal symptoms when trying to stop using drugs or alcohol? Have you had adverse reactions or overdose to drugs or alcohol? (Describe): Mental Health History Please check which of the following behaviors and symptoms you have: Aggression Elevated mood Phobias/fears Alcohol dependence Fatigue Recurring thoughts Anger Gambling Sexual addiction Antisocial behavior Hallucinations Sexual difficulties Anxiety Heart palpitations Sick often Avoiding people High blood pressure Sleeping problems Chest pain Hopelessness Speech problems Cyber addiction Impulsivity Suicidal thoughts Depression Irritability Thoughts disorganized Disorientation Judgment errors Trembling Distractibility Loneliness Withdrawing Dizziness Memory impairment Worrying Drug dependence Mood shifts Other (specify): Eating disorder Panic attacks Briefly discuss how the above symptoms impair your ability to function effectively: Is there any other information you would like me to know before we begin our discussion? 6
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PATIENT INFORMATION Please print clearly and complete all blanks
PATIENT INFORMATION Please print clearly and complete all blanks DATE: REFERRED BY: SEX: NAME: LAST FIRST MIDDLE BIRTHDATE: MAILING ADDRESS: CITY STATE ZIP TELEPHONE: CELL PHONE: WORK NUMBER: SS # MARITAL
Patient First Name Patient Middle Initial Patient Last Name. Primary Care Physician Primary Care Physician Phone Pharmacy Name
NP Hagans Walk-In Clinic * 9135 Piscataway Rd. # 320 Clinton, MD 20735 * (240)-412-5093 (Office) Patient Information Patient First Patient Middle Initial Patient Last Sex Marital Status Date of Birth Social
NEW PATIENT HEALTH HISTORY
NEW PATIENT HEALTH HISTORY Patient Name Today s Date Age Birth Date Date of last physical examination What is your reason for initial visit? Pharmacy Name & Telephone # NOTE: If you have prior records