Page 1 of 5 CUMMINS BEHAVIORAL HEALTH SYSTEMS, INC. CONSUMER MEDICAL HISTORY SELF-REPORT Please describe what problems you/consumer are having and why you are seeking treatment at this time. PRIOR MENTAL HEALTH/SUBSTANCE ABUSE TREATMENT SERVICES Do you have a Psychiatric Advance Directive? INPATIENT HOSPITALIZATIONS If yes, describe below: Where When Reason Response OUTPATIENT/OFFICE BASED If yes, describe below: Where When Reason Response Please list any MENTAL HEALTH medications that you have taken in the past but are no longer taking. Please describe any Family History of Mental Health or Substance Use Problems. DEVELOPMENTAL HISTORY While growing up, did you have any problems or delays in any of the following areas? Crawling Walking Talking Toilet Training Speech Socialization Other If yes, please explain:
Page 2 of 5 Please list ALL medications you are CURRENTLY taking including supplemental, herbal, and over the counter. If none, check here MEDICATION/DOSE ROUTE/FREQUENCY START DATE STOP DATE SIDE EFFECTS PHYSICIAN Do you have any allergies or Adverse Drug Reactions to previously prescribed drugs/medications? If yes, please explain: PHYSICAL HEALTH Have you, or a close relative ever been DIAGNOSED or TREATED for any of the following? Allergies Asthma Blood Disease Bone/Joint Disease Cancer Diabetes Endocrine Disease Fibromyalgia Gastrointestinal Head Injury Headaches Self Relative Self Relative Heart Disease Hepatitis High Blood Pressure High Cholesterol Kidney Disease Liver Disease Lung Disease Neurological Disease Obesity Stomach Disease Thyroid Disease
Page 3 of 5 Please explain your treatment regarding the above or indicate other health problems, if applicable: If female, are you pregnant? If female, have you had any past pregnancy or delivery complications? If yes, please explain: PRIMARY CARE Family Physician: Phone #: When was your last complete physical exam? Are your immunizations up-to-date? If no, what immunizations are needed? Are you currently receiving treatment from any other Physician or Practitioner? Yes No If yes, Name: Phone#: Specialty: Reason: Name: Phone#: Specialty: Reason: Please list all prior MEDICAL hospitalizations or significant medical procedures. None Have you had any serious accidents or injuries that continue to cause problems in your current functioning? If yes, please explain:
Page 4 of 5 NUTRITIONAL SCREEN Please indicate Yes or No for the person being assessed today. Yes No 1. Have you lost or gained more than 15 pounds in the last 3 months without trying? 2. Are you concerned that or have you been told that you are overweight or underweight? 3. Do you have trouble swallowing, chewing, or problems with your mouth that interfere with your ability to eat? 4. Have you been asked by a health care provider to follow a special diet but are having difficulty complying? 5. Do you have food allergies that make it difficult to maintain a healthy diet? PHYSICAL PAIN SCREEN Do you experience any persistent physical pain for which you are not receiving treatment? Please describe: Does the pain interfere with your ability to fulfill your activities of daily living? COMMUNICABLE DISEASE SCREENING Have you experienced any of the following symptoms or risks of tuberculosis (TB)? Persistent, productive cough Coughing up blood Loss of appetite Weight loss Night sweats Sharp/stabbing chest pain when inhaling Exposure to individual with TB Homelessness Resided in jail, shelter, nursing home Live in a known high risk TB area Have you ever been tested for TB? If yes, when and the results Have you ever engaged in any of the following behaviors associated with HIV and/or Hepatitis? Used IV drugs Multiple sex partners without protection? NA Have you ever been tested for HIV, Hepatitis, or a sexually transmitted disease? If yes, describe: Are you receiving treatment for any of the above medical concerns? If yes, describe: ADDITIONAL HEALTH SCREENING Has it been more than a year since your last physical exam? Have you noticed that you have excessive thirst or urination? Do you have open wounds or sores on your skin that do not seem to heal? Do you find yourself getting short of breath or experiencing chest pain with minimal activity? Do you have blurry vision, dizziness, and/or severe, persistent headaches with no known cause? The staff member completing your Intake can discuss the results of these screenings with you. Staff Initials:
Page 5 of 5 PROBLEM CHECKLIST Using the scale provided, please rate any of the following that apply to the consumer and that have been a problem in the past 30 days. 1 to 2 3 to 4 5 to 6 7 Mild Moderate Significant Severe N/A 1 2 3 4 5 6 7 - I cannot concentrate on things N/A 1 2 3 4 5 6 7 - I am easily distracted N/A 1 2 3 4 5 6 7 - I have difficulty making decisions N/A 1 2 3 4 5 6 7 - I cannot sit still N/A 1 2 3 4 5 6 7 - I cannot wait my turn to talk N/A 1 2 3 4 5 6 7 - I am easily annoyed or irritated N/A 1 2 3 4 5 6 7 - I often argue with other people N/A 1 2 3 4 5 6 7 - I lose my temper easily N/A 1 2 3 4 5 6 7 - I often argue with people in authority (i.e., bosses, teachers, parents) N/A 1 2 3 4 5 6 7 - I have had people close to me tell me that I drink/use drugs too much N/A 1 2 3 4 5 6 7 - I have tried to stop drinking/using drugs unsuccessfully N/A 1 2 3 4 5 6 7 - I am in trouble with the law/on probation N/A 1 2 3 4 5 6 7 - I sometimes spend money I can t afford to spend N/A 1 2 3 4 5 6 7 - I do not remember things well N/A 1 2 3 4 5 6 7 - I have long stretches of time that I do not remember N/A 1 2 3 4 5 6 7 - I have frequent crying spells, often cry for no reason N/A 1 2 3 4 5 6 7 - I often feel inadequate/worthless N/A 1 2 3 4 5 6 7 - I do not like being around other people N/A 1 2 3 4 5 6 7 - I do not leave my home often N/A 1 2 3 4 5 6 7 - I don t want to do things I used to like to do N/A 1 2 3 4 5 6 7 - I feel empty or lonely often N/A 1 2 3 4 5 6 7 - I cannot trust anyone N/A 1 2 3 4 5 6 7 - I have medical problems that doctors have told me are in my head N/A 1 2 3 4 5 6 7 - I believe that I have special or magical powers N/A 1 2 3 4 5 6 7 - I hear/see things other people tell me are not real N/A 1 2 3 4 5 6 7 - Sometimes I feel like I am outside my body N/A 1 2 3 4 5 6 7 - I don t eat enough N/A 1 2 3 4 5 6 7 - I eat too much N/A 1 2 3 4 5 6 7 - I have a strong fear of gaining too much weight N/A 1 2 3 4 5 6 7 - I have sleep problems N/A 1 2 3 4 5 6 7 - I feel helpless like nothing is going to change N/A 1 2 3 4 5 6 7 - I have bad nightmares N/A 1 2 3 4 5 6 7 - I have sexual problems N/A 1 2 3 4 5 6 7 - I have had bad things happen to me that I cannot forget about N/A 1 2 3 4 5 6 7 - My mood changes dramatically when the season changes N/A 1 2 3 4 5 6 7 - I cannot control how much I worry about things N/A 1 2 3 4 5 6 7 - I have times when I cannot shut my mind off N/A 1 2 3 4 5 6 7 - My mind goes blank sometimes N/A 1 2 3 4 5 6 7 - My heart beats too fast sometimes N/A 1 2 3 4 5 6 7 - There are times that I cannot get enough air to breathe N/A 1 2 3 4 5 6 7 - I feel like I have to do the same things over and over or something bad will happen N/A 1 2 3 4 5 6 7 - I believe, or others have told me, that I have a problem with perfectionism N/A 1 2 3 4 5 6 7 - I am afraid of things that do not bother most people Person completing this form is: Self Parent/Guardian Spouse/Significant Other Community Agency Representative Adult accompanying consumer Signature: Date: