PATIENT INTAKE: MEDICAL AND SOCIAL HISTORY (To be completed by patient)
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- Marian Casey
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1 NAME: DOB: Today's date: PATIENT INTAKE: MEDICAL AND SOCIAL HISTORY (To be completed by patient) Use the opposite side of the page as necessary to complete your answers. Please print legibly. Patient Name Address Phone (W) (H) (cell) DOB Age SS# Emergency Contact Relationship to patient Phone Primary care physician Phone Date of last physical exam Findings _ Have you ever had an EKG? ( )Y ( ) N Date Physician performing physical Current or past medical conditions (check all that apply) ( ) Asthma/respiratory ( ) Cardiovascular (heart attack, high cholesterol, angina) ( ) Hypertension ( ) Epilepsy or seizure disorder ( ) GI disease ( ) Head trauma ( ) HIV/AIDS ( ) Diabetes ( ) Liver problems ( ) Pancreatic problems ( ) Thyroid disease ( ) STDs ( ) Abnormal Pap smear ( ) Nutritional deficiency Childhood Illnesses Measles ( )N ( )Y Mumps ( )N ( )Y Chicken Pox ( )N ( )Y Have you ever been diagnosed with a psychiatric or mental illness or been hospitalized for mental health problems? (Please describe)
2 Please list all current prescription medications, dosages, and frequency of use (example: Dilantin, 300 mg capsules, 3x/day). DO NOT include medications you may be currently misusing (that information is needed later): Please list all current herbal medicines, vitamin supplements, etc. and how often you take them: Please list any allergies you have (penicillin, bees, peanuts): Have you ever been treated for substance abuse? ( ) Y ( ) N If yes, please describe when, where, and for how long: List current substances of abuse (including name, amount, frequency of use, how taken): 1) 2) 3) 4)
3 Substance Abuse History (Fill in each block) Alcohol Substance Not misused Currently misused Misused in past, but not currently Route of abuse How muc h abused How often abused Date/Time of Last Use Quantity last used Caffeine (pills or beverages) Cocaine Methamphetamine Inhalants LSD or other Hallucinogens Marijuana Heroin Methadone Narcotic Pain Medications (List) PCP Stimulants (example Ritalin) Benzodiazepines/ Sleeping Pills Ecstasy What was your longest period of abstinence? When was your longest period of abstinence? Current weekly cost of Substances of Abuse How long have you been misusing substances? Starting with what substance? 4
4 Tobacco History: Cigarettes: Now? ( )N ( )Y In the past? ( )N ( )Y How many per day on average? For how many years? For how many years? Pipe: Now? ( )N ( )Y In the past? ( )N ( )Y How often per day on average? For how many years? Provide details regarding your legal history, including DUIs, whether drug-related or not drug-related: _ Provide information regarding any history of violence, directed to self or to others: (Circle one) Married Single Divorced/Separated Current relationship: ( ) Long-term ( ) Short-term ( ) None Current Years married/in long-term relationship Times Married Times Divorced Children? ( ) N ( ) Y Current ages (list) Children residing with you? ( ) N ( ) Y If no, where and with whom? ) Do you have family nearby? ( ) Y ( ) N (Please describe) Education (check all degrees): ( ) Graduate school ( ) College ( ) Professional or Vocational School (list) ( ) High School Grade completed High School diploma or equivalency? ( ) Y ( ) N Are you currently employed? ( ) Y ( ) N If No, when were you last employed?
5 If yes, what kind of work are you doing now? How long have you worked there? What other type of work have you done in the past? History of abuse? ( ) Y ( ) N If Yes, indicate: ( ) physically ( ) sexually (including rape or attempted rape) ( ) emotionally Explain Are you now or have you ever attended: Alcoholics Anonymous Narcotics Anonymous ( ) Current ( ) Past ( ) Current ( ) Past Other 12-step type programs ( ) Current ( ) Past If yes, list If you are not now attending meetings, why not? Have you ever been in counseling or therapy? ( ) Y ( ) N (If yes, please describe): _ What are your goals with regards to treatment with Suboxone: Additional information that would be useful for me to know: _
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CHILD/ADOLESCENT SELF-REPORT FORM (To be completed before initial intake), LLC 2383 University Ave West, Suite 200 Saint Paul MN 55114 Phone: 651-644-4100 Fax: 651-644-4100 Date: Form Completed By: Relationship
Denise E. Bruner, M.D. & Associates, P.C.
page 1 of 6 NAME:(LAST) (FIRST) (M.I.) DATE OF BIRTH: / / SEX: M / F AGE: MARITAL STATUS: (please circle ONE) S M W D MEDICATION ALLERGIES Address (street) (city) (state) (zip) Phone numbers home: work:
Heartland Wellness Counseling Health Questionnaire
Heartland Wellness Counseling Health Questionnaire Today s Date: CLIENT INFORMATION Last name: First: Middle: Initial: Nick name: Marital status: Single Married Divorced Separated Widow Social Security