B. Medical History

Medical-Social History
NOTE: If the client is 18 years of age or older, the client is the only person permitted to complete and sign this form. If the client is under the age of 18, the parent or guardian must complete and sign this form.
Legal Name*

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Preferred Name
Today's Date

MonthDayYear
Date
Form Being Completed By:
Relationship to Client:
Presenting Problem
What are the 2-3 primary reasons you are seeking counseling/therapy?*
How long ago did you begin to be troubled by this problem?
List three (3) goals you would like to accomplish by attending counseling:*
Is this the first time you've seen a therapist/counselor for these issues?

YesNo
Please explain how previous counseling helped and/or didn't help you with these issues.
Symptoms Checklist

Check All Current Problems
Depressed Mood/Sad (as evidenced by)

Loss of interest in activitiesEmpty feelingFatigue/loss of energyThoughts of harming yourselfHopelessnessWorthlessnessTrouble concentratingIndecisivenessRecurrent thoughts of deathFeeling sad or depressedNone
Nutritional/Eating Pattern Changes/Disorders (as evidenced by)

Self-induced vomitingBinge eatingUse of laxativesIncrease in appetiteDecrease in appetiteExcessive exercisingWeight gainWeight lossNone
Pain Management (as evidenced by)

Pain interferes with activitiesNone
Grief Issues (as evidenced by)

Loss of loved one in past yearNoneOther
Traumatic Stress (as evidenced by)

Recurrent/intrusive/distressing thoughts/imagesRecurrent dreams/nightmaresStartles easilyExposure to traumatic eventNone
Anger/Aggression (as evidenced by)

Threatens/intimidates othersInitiates fightsPhysically hurts peoplePhysically hurts animalsUse of weaponsNone
Oppositional Behaviors (as evidenced by)

Loses temperArguesDeliberately annoys othersBlames othersEasily annoyedAngry and resentfulSpiteful/vindictiveNone
Anxiety (as evidenced by)

Excessive worryRestlessnessObsessionsMuscle tensionIrritabilityCompulsionsDifficulty breathingPounding heartExcessive checkingStrong fearsShakingExcessive hand washingNone
Inattention (as evidenced by)

Difficulty sustaining attentionTrouble waiting for turnRapid or extreme changes in moodDecreased need for sleepIrritabilityInflated self-esteemNone
Addictive Behaviors (as evidenced by)

GamblingInternetShoppingNoneOther
Sleep Problems (as evidenced by)

Difficulty falling or staying asleepSleepwalkingFrequent nightmaresExcessive sleepinessNone
Stressors
Past Diagnosis

YesNone
Please explain the diagnosis you received.
Who was diagnosed? Name
When was the diagnosis? Date
Family history of mental health?

YesNone
Diagnoses? Name
Past trauma history?

YesNone
Past traumatic experience(s)

Physical abuseSexual abuseRapeAssaultDomestic violenceViolence in my neighborhoodNatural disasterMilitary traumaWarRefugeeIdentity theftLoved one with severe mental illnessExperiencing oppressionPartner struggles with addictionUndiagnosed learning disabilityReside in low income neighborhoodReside in high crime neighborhoodInfertility challengesInfidelityImmigrating from another countryMiscarriageChronic illnessRecent surgery/hospitalizationBeing bullied or cyberbulliedReligious traumaChaotic childhoodParent or sibling alienationNeglectPovertyDeath of a loved oneDeath of a petServed time in jailArrestedOther
When did the incident(s) occur? Name
Psychiatric hospitalizations?

YesNone
Spiritual/Religious Beliefs?
What is important in a therapeutic relationship?
Living Situation
My Home

RentOwnRelatives HomeOther
Please list household information (use "+" to add more)
Please list additional household information (use "+" to add more)
Education, Employment, and Military Information
Education History

G.E.DHigh School GraduateCollegeCollege Graduate
College
Degree/Major
Other Degrees Completed:
History of Learning Difficulties (including performance/behavioral problems due to AUD use)

None reportedLearning disability typeDevelopmental disabilityOther
Explain
Special Communication Needs

None reportedTDD/TTY deviceSign Language interpreterAssistive listening device(s)Language interpreter services needed/other spoken languageOther
Please Explain
Employment or School (check all that apply)

Full-time (more than 35 hrs. per week)Part-time (less than 35 hrs. per week)Non-competitiveUnemployedStudentDisabled - not working
Date Last Worked Or Attended?

MonthDayYear
Date
If employed, name of employer
Current job title
Job Performance History
Number of jobs in past 5 years
Comments
(include performance/behavioral problems due to alcohol or drug use)
Attendance

Above averageNormalTardinessAbsenteeism
Are you satisfied with your job?

YesNo
Performance

ExemplaryGoodAverageBelow average
Are you experiencing financial problems?

YesNo
(If not currently employed) Do you want to work?

YesNo
COMMENTS ON PAST OR CURRENT EMPLOYMENT/EDUCATION SKILLS/INTEREST
(Include information relating to past or current employment/education skills and interest
Military History

YesNo
PLEASE DESCRIBE BRANCH OF SERVICE, ANY PERTINENT DUTIES, AND ANY TRAUMA EXPERIENCED DURING SERVICE, AS APPLICABLE
Type of Discharge?
If other than General/Honorable
Legal History
Legal Guardians/Custodian - Name, Address, and Phone Number
History or Legal Charges

NoYes
Yes, please explain

MisdemeanorFelonyOther:
Explain
List and Date of Most recent charges
Convictions?

YesNone reported
Please Explain Convictions
Name and Phone Number of Probation/Parole Officer (If applicable)
Civil Proceedings?

YesNo
Domestic Relations Court Problems
*i.e., custody, protective services, restraining order)
Juvenile Court Involvement (Related to child abuse, neglect, or dependency)

NoYes (currently)Yes (past)
Currently, Please Explain
Past, Please Explain
Child Protective Services involvement with family

None reported
Name of Children's Protective services Caseworker(s) Assigned to Family (If applicable)

None reportedOther
Adult Health History Questionnaire
Have you had any of the following health problems?

AnemiaArthritisAsthmaBleeding disorderBlood pressure (high/ low)Bone/joint problemsCancerCirrhosis/liver diseaseDiabetesEpilepsy/seizuresEye disease/blindnessFibromyalgia/muscle painGlaucomaHeadachesHead injury/brain tumorHearing problems/deafHeart diseaseDepatitis/jaundiceKidney diseaseLung diseaseMenstrual painOral health/dentalStomach/bowel problemsStrokeThyroidTuberculosisAIDS/HIVSexual problemsLearning problemsSpeech problemsAnxietyBipolar disorderDepressionEating disorderHyperactive/ADDSchizophreniaSexually transmitted diseaseSleep disordersSuicide attempts/thoughts
Which of these were in the past?
Which of these are you dealing with now?
What treatments were received and date(s) (medication/5-3-2009)
Current Medication Information

(medical and psychiatric prescription/OTC/herbal)
Medications*

I am currently taking medication(s)I am not taking medication(s)
Please list your current medications
Contact information for Primary Care Physician*

I have a Primary Care PhysicianI do not have a Primary Care Physician
Primary Care Physician contact information:
Other Prescribing Physician(s)
Past Psychiatric Medications
IF No Past of Psychiatric Medications

None Reported
Have you had medical hospitalization/surgical procedures in the last 3 years?

YesNoExplain:Other
Allergies/Drug Sensitivities

NoneFoodMedicineOther
Food (specify)
Medicine (specify)
Other (Specify)
Pregnancy History

Not pertinent
Currently Pregnant?

YesNo
Any Significant Pregnancy History?

YesNo
Explain Pregnancy Related Issues
Medical Information
Last Physical Examination
Have you had any of the following symptoms in the past 60 days?

Ankle swellingBed wettingBlood in stoolBreathing difficultyChest painConfusionConsciousness lossConstipationCoughingCrampsDiarrheaDizzinessFallingGait unsteadinessHair changeHearing lossLightheadedMemory problemsMole/wart changesMuscle weaknessNervousnessNosebleedsNumbnessPanic attacksPenile dischargePulse irregularitySeizuresShakinessSleep problemsSweats (night)Tingling arms and/or legsTremorUrination difficultyVaginal dischargeVision changesVomitingOther
Immunizations - have you had or been immunized for the following diseases? (please check all that apply)

Chicken PoxMumpsDiphtheriaPolioGerman MeaslesSmall PoxHepatitis BTetanusMeaslesOther
Immunizations within the past year
Has client's weight changed in the past year?

NoYes
By how much ( + or - ) and how often
Nutritional Screening
If No Problem

Select
Eating

MoreLessNot eating
Drinking

MoreLessTakes liquid only
Appetite

IncreasedDecreased
Explain any issues:
Pain Screening
Does pain currently interfere with your activities?

NoYesNot at allMildlyModeratelySeverelyExtremely
Please indicate the source of pain
CAGE-AID Questionnaire: Substance use screening tool

When thinking about drug and alcohol use in the last 90 days, include illegal drug use.

	NO (0) points each	YES (1) point each
C. Have you ever felt that you ought to Cut down on your drinking or drug use?
A. Have people Annoyed you by criticizing your drinking or drug use?
G. Have you ever felt bad or Guilty about your drinking or drug use?
E. Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover (Eye opener)?

CAGE-AID Score
Substance Use History / Current Use
Which of the Following have you used?

BeerWineLiquorHeroinBarbituratesAmphetaminesCrackCocaineMarijuana/hashishLSDInhalantsPCPMDMA (XTC)Prescription drugs off the streetNon-prescription drugs by injectionOther
Beer
Wine
Liquor
Heroin
Barbiturates
Amphetamines
Crack
LSD
Marijuana / Hashish
Inhalants
PCP
MDMA (XTC)
Prescription drugs off the street
Non-Prescription drugs by injection
Cocaine
Caffeine
Nicotine
Is this for a child?

YesNo
Custodial Parent
Pertinent Developmental Issues
Mothers Pregnancy History (include prenatal exposure to alcohol, tobacco, and other drugs)

No problems reportedYes
Please Explain
Infancy (Ages 0 - 1)

No problems reportedYes
Please Explain
Preschool (Ages 2 -4)

No problems reportedYes
Please Explain
Childhood (Ages 5 - 12)

No problems reportedYes
Please Explain
Adolescent (Ages 13 - 17)

No problems reportedYes
Please Explain
Family Environment/Relationships
Parent-Child (Client) Relationship(s):*

Not applicablePrimary householdSecondary householdBoth
Comment on Parent-Child Relationship(s): (could include parent-child conflict, parent supervision and monitoring of child, cooperation between parents regarding child rearing, parent positive activities with child, parent satisfaction with relationship, child satisfaction with relationship(s))
Sibling-Child (Client) Relationship(s)

Not applicablePrimary householdSecondary householdBoth
Comment on Sibling-Child Relationship(s): (could include sibling-child conflict, positive activities with child, sibling satisfaction with relationship, child satisfaction with relationship(s))
Parent Marital or Couples Relationship(s):

Not ApplicablePrimary householdSecondary householdBoth
Comment on Parent Marital or Couples Relationship(s): (could include marital or couples conflict, marital or couples satisfaction with relationship(s))
School Functioning
Regular Education Classes? (No Special Services)

YesNo
Any School Related Concerns:
Print Name Of Person Completing This Questionnaire
Date

MonthDayYear
Date
Signature

Clear
Should be Empty:

Medical-Social History