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Transcription:

Health History Form Age: Your answers on this form will help your health care provider get an accurate history of your medical concerns and conditions. If you are uncomfortable with any question, do not answer it. Thank you! Main reason for today s visit: Other concerns: Referred by: Height Most recent weight Birthdate: Given the list of categories below, how much stress is each currently causing you? None Mild Stress Moderate Stress Severe Stress Family Friends Relationships Educational Economic Occupational Housing Legal Health Describe your typical sleep pattern: Appetite over the past 2 weeks (refers to desire to eat): Good Fair Poor Current eating disorder: No Yes History of eating disorder: No Yes Unsure Describe your usual breakfast: Dietary restrictions? How do you feel about exercise? Is violence at home a concern for you now? No Yes Has violence at home ever been a concern? No Yes Have you ever experienced trauma (check if yes)? Physical Emotional Verbal Sexual Other In the past 2 weeks, have you been bothered by: Little interest or pleasure in doing things? No Yes Feeling down, depressed or hopeless? No Yes Thoughts of hurting yourself or someone else? No Yes Thoughts things might be better if you weren t here? No Yes REVIEW OF SYMPTOMS: Please mark any persistent symptoms you have had in the past few months. Chronic pain. If yes, where? Beginning when? Concerns/Complaints regarding (circle): eyes / ears / nose / throat / heart / breathing / muscles / bones or joints / gut / blood clots / easy bruising / urinary system / genitals / nervous system / skin 1

Tremors or worrisome movements Headache Numbness / tingling Chest pain / discomfort Shortness of breath or sensation of choking Gender-identity concerns Nausea and/or vomiting Fainting/Dizziness Memory loss Unsteady gait Heart palpitations Hot flashes / Night sweats Insomnia or sleep problems Weight loss/gain OB/Gynecologic Pregnant If yes, Due Date Perimenopause/Menopause Infertility Concern with sexual function Postpartum Delivery Date Nursing Pelvic pain Gender affirming surgery/hormones Psychiatric Suicidal thoughts Seeing /Smelling/Hearing/Feeling things that others say aren t there Anxiety/stress Irritability Frequent crying Memory loss Difficulty concentrating Depression Apathy/Feeling like things don t matter Anger Intense fear Pre-menstrual symptoms (anxiety, irritability, mood changes) Other concerns you d like to discuss: Caffeine intake: Tobacco Use: Never Not currently Yes How? Cigarettes Pipe Cigar Snuff Chew Former smoker: Quit date: How many years did you smoke? Packs/day? Current smoker: Packs/day: # of years: Are you interested in quitting at this time? Alcohol Use: Do you drink alcohol? No Yes # of drinks/week: Are you interested in quitting at this time? No Yes Drug Use: Do you use marijuana? No Yes, since age: What kind and in what form? How much & how often? Recreational drugs? No Yes History of previous heavy or regular drug use? No Yes Please list types, frequency, and when use began Are you interested in quitting at this time? No Yes Have you ever received any treatment for substance abuse? No Yes 2

Preferred Pharmacy (include location): Primary care provider: Phone number: Address: MEDICATIONS: Please all prescriptions and non-prescription medications, vitamins, birth control pills, herbs, etc. Include dose and frequency. Use the back of this form if you need more room. I TAKE NO MEDICATIONS or SUPPLEMENTS (including birth control) Allergies or intolerance to medications or food (include type of reaction) NONE Surgical History: Please note any surgeries. List dates and any abnormal finding or complications. NONE Reproductive health plan: *Applies to both male and female clients: Do you plan to pursue pregnancy within the next year? No Yes Method of contraception: OB/GYN HEALTH HISTORY: Total number of pregnancies: Infertility problems or treatment: Number of live births: Miscarriages or terminations (before 20 weeks): Miscarriages or terminations at or after 20 weeks: Postpartum complications (infection, chronic pain, sick baby, etc): No Yes History of a traumatic pregnancy/birth/infertility experience? No Yes How often do you get your period? Are they regular? Age at end of periods (menopause): Do you notice your mood changes significantly with your cycle? No Yes Have you ever used psychiatric medications? No Yes (Please list prior meds) How many times have you been hospitalized for psychiatric reasons? Ever hurt yourself on purpose? No Yes History of suicide attempts? No Yes How else have you treated mental health concerns now or in the past? Have you ever been an abusive toward others? No Yes Have you had a history of violent behavior? No Yes 3

Is there something you re hoping to achieve with mental health treatment? PERSONAL MEDICAL HISTORY Anemia Asthma/Breathing problems Autoimmune Disorder Bladder/Kidney problems Cancer Chronic Fatigue Syndrome Diabetes Fibromyalgia Head Injury Heart Attack or other heart High Blood High Cholesterol HIV or AIDS Gut diseases or disturbances Kidney disease Liver Disease or Hepatitis Migraine headaches Seizures/Epilepsy Sleep apnea Stroke Thyroid Disease Alcohol/Drug abuse Other addictions Depression Anxiety Obsessive-Compulsive Traits Eating Disorder Self-harm (cutting, etc.) Bipolar disorder/manic-depression Schizophrenia Personality Disorder PTSD ADHD/ADD Autism Yes Comments (onset, persistent or resolved, major treatments, etc) (adult, childhood, gestational?) Loss of consciousness? (overactive or underactive?) (i.e., gambling, food, sex, etc.) 4

FAMILY HISTORY Alzheimer s/dementia Diabetes Fibromyalgia Heart Problems High Blood Pressure Thyroid Disease Migraine Headaches Parkinson s Sudden death Suicide Alcohol/Drug abuse Other addictions (i.e., sex, gambling, etc.) Depression Anxiety OCD Hormonal mood changes (severe PMS, postpartum depression, anxiety, psychosis, etc.) Bipolar disorder/ Manic-Depression Schizophrenia Personality Disorder PTSD ADHD/ADD Mother (Biological) Father (Biological) Sister(s) # Brother(s) # Mom s Mom Mom s Dad Dad s Mom Dad s Dad Other Relatives (*including your children) Comments Developmental History: Did you have any delays or difficulties in reaching the following developmental milestones? Walking Talking Toilet training Sleeping alone Being away from parents Making friends Which options below best describe your childhood home atmosphere? Supportive Parental fighting Parental violence Financial difficulties Frequent moving Other: Which of the following challenges were experienced during your childhood? (please circle all that apply) Enuresis (bed wetting) Tantrums Property damage Encopresis (fecal incontinence) Fire setting Animal cruelty Running away from home Depression Victim of bullying Death of a parent/caregiver Fighting Engaged in bullying Separation anxiety Stealing Parental divorce Which of the following best describe problems you may have had in school? (please circle all that apply) Fighting School phobia Truancy Detentions Suspensions Expulsions School refusal Class failures Repetition of grades Special education Remedial classes Last grade completed or highest degree: 5

SOCIAL HISTORY: Were you raised by: biological parent(s) adoptive parent(s) Other: Do you have a religion or spiritual practice? No Yes: Please list previous faiths: I don t have guns. If you have guns in your home, are they locked up? No Yes Occupation other than parenting (or prior occupation): Part-time Fulltime Unemployed Leave of absence Retired Which options below best describes your social situation? Supportive social network Distant from family of origin Few friends Family conflict Substance-use based friends Other: No friends Sexual orientation: Homosexual Bisexual Pansexual Heterosexual Transgender? No Yes Preferred pronoun: he/she/they Relationship status (circle one): single, partnered, married, divorced, widowed, other: Number of times you ve been married: Spouse/partner s name: How satisfied are you with your current relationship? Names and ages of children: Who lives at home with you (include pets, friends, temporary longterm guests)? Please note anything else you d like to include: Thank you for taking the time to fill this out. 6

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