Social Worker Intake Form

Primary Care Physician's Name

First NameLast Name

Date of Last Physical

MonthDayYear

Other medical health specialist currently seeing?

Please list any persistent physical symptoms or health concerns (e.g. chronic pain, headaches, hypertension, diabetes, etc.

Are you currently on medication to manage a physical health concern? If so, please list medications

Do you have any sleeping disorders?

Do you have any eating disorders?

How many hours do you exercise on weekly basis?

How many cigarettes or other tobacco products you use in daily basis?

In what range do you use alcohol on monthly basis?

How often do you engage in recreational drug use?

Have you ever experienced any of the following?

Has anyone in your family experienced any of the following?

If answered yes to any of the above, please list the member and their condition

What are your strengths?

What are your weaknesses?

Personal Information