Health Information Form Please enable JavaScript in your browser to complete this form.Please read each of the following and initial in the box directly below indicating you knowledge and understandingNameTodays DateMM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Reason for entering into services?Please check any symptoms that describe how you feel, think, or behave currently or within the last 3 months:Abdominal painAggressive/abusive towards otherAgitationAttempts to harm selfAvoidance of public placesBack painChange in ability to walkChest painChest tightnessChronic sadnessConfused/worried about sexual behaviorConstipationCrying episodesDiarrheaDifficulty at work/schoolDifficulty completing tasksDifficulty concentratingDifficulty focusingDifficulty functioning sociallyDifficulty making decisionsDifficulty waiting your turnDizzinessEasily startledExcessive gamblingExcessive spendingExcessive worryFaintingFear of dyingFear of leaving homeFear of loss of controlFearfulnessFrequent forgetfulnessFrustrationHard to stay with job very longHopelessnessIntrusive thoughts of bad memoriesIrritabilityLegal problemsChange in eating habits: stress eating/loss of appetiteLow energy/fatigueMarital conflictMemory problemsMultiple sexual partnersMuscle stiffnessMuscle weaknessNausea/VomitingNeck PainNightmaresNot well organizedOvereatingPanic attacks Physical abusePounding heart/palpitations Problems with co-workersRacing thoughts Reduced interest in activitiesRe-living bad experiencesRestlessnessSchool problemsSeeing/hearing things others don’tSeizuresSexual abuse/rape (recent or past)Shortness of breathSleep problemsSnoringStaying up for days without sleepTaking on too many tasksTendency to act impulsivelyThoughts of physically hurting othersThoughts of suicide/homicide Trembling/shakingVision changesWithdraw from othersSelf-Injury without suicide attempt (i.e. cutting, hair pulling, and banging of head etc.)Please describe why you are seeking help at this timeHas any member of your family been hospitalized for mental health concerns?YesNoIf yes, please list who, when and for what reasonDo/did you have any family members who have/had problems with drinking alcohol or using drugs?YesNoIf yes, please list who, when and if it is still a problemHas any member of your family attempted/committed suicide?YesNoIf yes, Please list who, when, and what happenedWhat 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?YesNoIf yes, please list who, when and whyHave you ever been hospitalized for mental health or drug/alcohol concerns?YesNoIf yes, please list when and for what reasonDo you have thoughts of harming yourself?YesNoIf so, how often does this happen?Have you ever tried to harm yourself?*YesNoIf so, when did this happen?Did you receive medical help at the time?YesNoCurrent Medications. If none, please leave blank.(Please include prescription, over the counter, herbs, vitamins, and other remedies) Medication 1Dosage/when takenReason takingPrescribing DoctorMedication 2Dosage/when takenReason takingPrescribing DoctorMedication 3Dosage/when takenReason takingPrescribing DoctorMedication 4Dosage/when takenReason takingPrescribing DoctorMedication 5Dosage/when takenReason takingPrescribing DoctorMedication 6Dosage/when takenReason takingPrescribing DoctorMedication 7Dosage/when takenReason takingPrescribing DoctorMedication 8Dosage/when takenReason takingPrescribing DoctorMedication 9Dosage/when takenReason takingPrescribing DoctorMedication 10Dosage/when takenReason takingPrescribing DoctorMedication 11Dosage/when takenReason takingPrescribing DoctorMedication 12Dosage/when takenReason takingPrescribing DoctorMedication 13Dosage/when takenReason takingPrescribing DoctorAllergies to medications*Please list any current medical problems or concerns*Please list any past serious illnesses, surgeries or health concerns*Exercise and Physical Recreational ActivityType of activity & How often*Would you describe yourself as physically active?*Do you currently have a primary care physician? If so, please list his/her name:*Are you currently under the care of any other physicians? If so, please list names:*Use of substances (on average) If none, please leave blank. Alcohol?YesNoCurrent Amount. (Number per day)Current Amount. (Number per week)Current Amount. (Number per episode)Current Amount. (Type of alcohol) (Beer, Whiskies, Wine, Etc)Current Amount. (Size of drinks) (Can, Tallboy, Shots, Etc.)Most used in Past. (Number per day)Most used in Past. (Number per week)Most used in Past. (Number per episode)Most used in Past. (Type of alcohol) (Beer, Whiskies, Wine, Etc)Most used in Past. (Size of drinks) (Can, Tallboy, Shots, Etc.)TobaccoYesNoCurrent Amount. (Cigarettes per day)Current Amount. (Cigars per day)Current Amount. (Smokeless cans per day)Most used in Past. (Cigarettes per day)Most used in Past. (Cigars per day)Most used in Past. (Smokeless cans per day)Caffeine(tea, coffee, soda)YesNoCurrent Amount. (Servings per day)Most used in Past. (Servings per day)MarijuanaYesNoCurrent Amount. (per day)Current Amount. (per week)Most used in Past. (per day)Most used in Past. (per week)CocaineYesNoCurrent Amount. (times per day)Current Amount. (times per week)Most used in Past. (times per day)Most used in Past. (times per week)PillsYesNoCurrent Amount. (pills/doses per day)Current Amount. (pills/doses per week)Current Amount. (Type of pills. (pain pill, Xanax etc.)Most used in Past. (pills/doses per day)Most used in Past. (pills/doses per week)Most used in Past. (Type of pills. (pain pill, Xanax etc.)Use of the below substances (on average) If none, please select None.*CocaineMethamphetaminesHeroinMollyHallucinogens - Mushrooms/Mushroom tea, LSD, etc.EcstasySynthetic drugs i.e. bath salts, spice etc.None of the AboveOtherIf you selected OTHER, please nameIf you need to list more than one, please list themCurrent Amount. (How often used. Daily, Weekly, Occasional?)Current Amount. (Amount used?)Most used in Past. (How often used. Daily, Weekly, Occasional?)Most used in Past. (Amount used?)Marital statusHave you ever been married/partnered?How many times?Longest relationship?Reason for ending marriages/partnerships? Number of Children?Do you have custody?If no, who has custody?Education?Difficulties with education?Living arrangements?Employment?Military Service? (What Branch?)Military Service? (Active duty/Discharged/Retired?)If discharged type of discharge?MOS? (Job in Military)Combat Experience?YesNoMilitary sexual trauma?YesNoAre you currently eligible for or receiving VA Benefits/Treatment?YesNo*If you need records sent to the VA please provide a release of information and specify which VA facility/department records need to be sent to:Submit
