• HEALTH QUESTIONNAIRE

  • TODAY'S DATE:
     / /
    2 digit month, 2 digit day, 4 digit year
  • Birthdate:
     / /
    2 digit month, 2 digit day, 4 digit year

  • HEALTH HISTORY:

  • Do you have any FOOD or DRUG ALLERGIES:
  • Do you have any physical impairments or limitations which may require special accommodations, special arrangements, or may affect your treatment (i.e. reading difficulties, hearing loss, vision loss, speech impairment)?
  • How would you describe the nutritional value and balance of your diet:
  • Do you exercise regularly:
  • Are you currently on any physician prescribed medications or regularly take any “over-the-counter” or herbal medications, including any prescriptions for anxiety, depression, or other mental health conditions?
  • Symptoms in the past 6 months:
  • Medications
  • In the past, have you ever taken medication for a mental health condition?
  • Hospitalizations / surgeries?
  • Do you have any medical conditions?
  • Any Complications?
  • Have you ever had a miscarriage?
  • Have you ever had an abortion?

  • BEHAVIORAL HEALTH

  • Have you had prior psychiatric counseling or alcohol/drug treatment?
  • OUTPATIENT
  • INPATIENT

  • SUBSTANCE USE HISTORY:

  • Have you experienced any of the following problems as a result of alcohol, prescription medications, or other drug use?
  • Has anyone in your family had problems with alcohol or other drug use?
  • Please indicate the following:
    Rows

  • HISTORY OF ABUSE:

  • Have you ever experienced:

  • CULTURAL/ETHNIC/SEXUAL:

  • Military Service?
  • Were you involved in combat duty?
  • Currently employed?
  • Diploma?

  • SPIRITUAL HISTORY:

  • Is spirituality an important resource for you?

  • If yes, does your practice of spirituality include:

  • Attendance at religious services?
  • Practice of spiritual disciplines such as prayer, reading, or meditation?
  • Involvement in some type of ministry?
  • Involvement in a small group or with a spiritual director or mentor?

  • FAMILY HISTORY:

  • Is there any history of emotional / mental health problems, or suicide in the family?

  • MARITAL HISTORY:

  • Martial status

  • LEGAL HISTORY:

  • Have you ever had involvement with the legal system?
  • Do you have any current pending legal charges?
  • Are you currently on probation or parole?
  • Have you ever been incarcerated?

  • The information I have provided above is true to the best of my knowledge.

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: