Behavior Health Admission Information Form. Name Date

Transcription

1 Behavior Health Admission Information Form Name Date What symptoms are you experiencing? Depressed Mood Anxiety Agitation Hopelessness Suicidal Thoughts Worthlessness Guilt Anger Difficulty Concentrating Lack of Motivation These questions pertain to the past month: Loss of energy Social Isolation Memory problems Difficulty making decisions Excessive Fear Hallucinations Mood Swings Manic Symptoms Impulsive Behavior Sensitivity Increased Have you ever wished you could go to sleep and not wake up? Grief/Loss Memory problems/confusion Unusual thoughts/ideas Sleep Disturbance (less sleep) Sleep Disturbance (oversleep) Weight gain Substance withdrawal Symptoms associated with an eating disorder Psychological Trauma Have you had thoughts of killing yourself? Have you been thinking of how you might do this? Are you intending on acting on these thoughts? Have you started working out details on how to kill yourself? Have you ever done anything, started to do anything, or prepared to do anything to end your life? How long ago did you do any of these? Within the last three months Between three months and a year ago Over one year ago Do you have access to guns or weapons? Do you currently engage in self-injury behavior? Cutting Hair Pulling Burning Head Banging Other Have you engaged in self-injury behavior in the past?, type of self-injury Have you ever threatened, attempted to harm or physically harmed someone? How many times has this occurred? N/A or more

2 How old were you the first time it occurred? N/A 40 or older under 20 Have you been having thoughts to harm or kill others? Medical History Diabetes Type I Diabetes Type II High Blood Pressure High Cholesterol High Triglycerides Heart Attack Heart Failure Atrial Fibrillation Blood clots/clotting disorder Stroke/TIA Head Injury Seizures Migraines Anemia HIV Sexually transmitted disease Hypothyroid Skin Disorder Respiratory problems Asthma Bowel disease Cancer Chronic Pain Hearing Problems Vision Problems Learning Disability Other Surgical History Substance Use Past Use: Amphetamines Cocaine Ecstasy Hallucinogens/LSD Heroin Inhalants/Glues/Solvents Marijuana Methamphetamines Prescription/Pain medications Other Age of Use Previous Substance Use Treatment: ne Inpatient Outpatient Other Cocaine Ecstasy Hallucinogens/LSD Heroin Inhalants/Glues/Solvents Marijuana Methamphetamines Prescription/Pain medications Other Last use: Current Use: Amphetamines

3 How often did you have a drink containing alcohol in the past year? In the past year, how many drinks did you typically have when you drank? How often did you have 6 or more drinks on one occasion in the past year? never less than monthly 2 to 4 times per month 4 or more times per week 1 or 2 3 or 4 5 or 6 7 or 8 10 or more never less than monthly monthly weekly daily Have you ever been treated for an alcohol problem or attended AA? Previous Treatment for Alcohol Use: What type of alcohol do you drink? When was your last drink? ne Alcoholics Anonymous Inpatient Outpatient Other Beer Wine Liquor Other Date: Health History How much do you exercise? Have you had any change in your ability to take care of yourself or do your usual activities? i.e hygiene, laundry, cleaning, cooking, shopping, chores, work, leisure, etc t currently exercising I spend minutes per day exercising times per week Type of exercise you do:, Please describe Are you sexually active? Describe your sexual orientation: Heterosexual Homosexual Bisexual How do you identify your gender? Female Male What type of contraception do you use? ne Condoms Other:

4 Have any changes in appetite, ability to eat, foods/weight changes affected you?, please describe How may meals do you eat per day? meals snacks What are your eating patterns? rmal eating behavior Preoccupation with weight Binge Eating Poor body image Vomit after Eating Calorie Restriction Under Eating Over Eating Laxative Use Lack of appetite Increased appetite How much weight gain/loss have you had over the past 6 months? What type of diet do you follow? What are your sleep patterns? lbs weight gain lbs weight loss change Regular diet Gluten free Diabetic Lactose Free Vegetarian Vegan Low Cholesterol Low Fat Other: rmal sleep pattern Early morning awakening Difficulty awakening Difficulty falling asleep Frequent urination at night Middle of night awakening Night terrors Nightmares Oversleeping Restless sleeper Sleep walking Sleep Apnea Number of hours per night you are sleeping Spirituality Do you have specific ethnic, cultural, spiritual practices that would affect your care? Do you practice a specific religion? Do you wish to speak with a member of the pastoral staff? Abuse History

5 Have you ever been sexually, emotionally, or physically abused by your partner, caregiver, or someone important to you? Within the last year, have you been hit, kicked or otherwise physically hurt by someone? Within the last year, has anyone forced you to have sexual activity? Are you afraid of your partner, car giver, or anyone else? If you answered yes to any of the above questions, please explain further. Tobacco Use Never smoker Former smoker, quit more than 1 year ago Former smoker, quit 1 month to 1 year ago Former smoker, quit within the last 30 days Current some day smoker Current every day smoker Type of Tobacco Cigar Cigarettes Pipe Chewing Tobacco Snuff E-Cigarettes Age started to use Amount of tobacco per day: Do you have a history of falling? If yes, when was your most recent fall? Do you use a walking aid? Do you have problems with balance?, please explain Immunizations Have you had a flu shot this season?, date Have you had a Pneumonia Shot in the last 5 years?, date