Health Information Form

Name

Todays Date

Reason for entering into services?

Please check any symptoms that describe how you feel, think, or behave currently or within the last 3 months: Please check any symptoms that describe how you feel, think, or behave currently or within the last 3 months: Abdominal pain Aggressive/abusive towards other Agitation Avoidance of public places Back pain Change in ability to walk Chest pain Chest tightness Chronic sadness Confused/worried about sexual behavior Constipation Crying episodes Diarrhea Difficulty at work/school Difficulty completing tasks Difficulty concentrating Difficulty focusing Difficulty functioning socially Difficulty making decisions Difficulty waiting your turn Dizziness Easily startled Excessive gambling Excessive spending Excessive worry Fainting Fear of dying Fear of leaving home Fear of loss of control Fearfulness Frequent forgetfulness Frustration Hard to stay with job very long Hopelessness Intrusive thoughts of bad memories Irritability Legal problems Change in eating habits: stress eating/loss of appetite Low energy/fatigue Marital conflict Memory problems Multiple sexual partners Muscle stiffness Muscle weakness Nausea/Vomiting Neck Pain Nightmares Not well organized Overeating Panic attacks Physical abuse Pounding heart/palpitations Problems with co-workers Racing thoughts Reduced interest in activities Re-living bad experiences Restlessness School problems Seeing/hearing things others don’t Seizures Sexual abuse/rape (recent or past) Shortness of breath Sleep problems Snoring Staying up for days without sleep Taking on too many tasks Tendency to act impulsively Thoughts of physically hurting others Thoughts of suicide/homicide Trembling/shaking Vision changes Withdraw from others Self-Injury without suicide attempt (i.e. cutting, hair pulling, and banging of head etc.)

Please describe why you are seeking help at this time

Has any member of your family been hospitalized for mental health concerns? Has any member of your family been hospitalized for mental health concerns? Yes No

If yes, please list who, when and for what reason

Do/did you have any family members who have/had problems with drinking alcohol or using drugs? Do/did you have any family members who have/had problems with drinking alcohol or using drugs? Yes No

If yes, please list who, when and if it is still a problem

Has any member of your family attempted/committed suicide? Has any member of your family attempted/committed suicide? Yes No

If yes, Please list who, when, and what happened

What is your best memory about your family when growing up?

If you could change anything about your family situation right now, what would it be?

Have you ever seen a counselor, psychologist, psychiatrist, or other mental health professional for any mental health or drug/alcohol concerns? Have you ever seen a counselor, psychologist, psychiatrist, or other mental health professional for any mental health or drug/alcohol concerns? Yes No

If yes, please list who, when and why

Have you ever been hospitalized for mental health or drug/alcohol concerns? Have you ever been hospitalized for mental health or drug/alcohol concerns? Yes No

If yes, please list when and for what reason

Do you have thoughts of harming yourself? Do you have thoughts of harming yourself? Yes No

If so, how often does this happen?

Have you ever tried to harm yourself? Have you ever tried to harm yourself? Yes No

If so, when did this happen?

Did you receive medical help at the time? Did you receive medical help at the time? Yes No