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1 - Health History (PA)

People to People
1200 E. Wheeling Ave.
Phone 740-432-1800
 Client Information
  First Name:  * Last Name:  *  
           
  Date of Birth:  * Birth Sex: 
* 
         
  Address: City:  
  State: Zip Code :  
  Phone No:  
* Date of Service
 
Date
How did you hear about us?
Presenting Problem    Why are you seeking services?
Other areas of concerns:    i.e housing, employment, disability application, job training, time/money management, applying skills outside of session, relationships, public assistance needs, school/grades, living skills, transportation
How do you know it is a problem?    Frequency of symptoms
Maintenance of problem    What have you done or are doing to deal with this problem?
What do you want to get out of therapy?    Ex. Coping Skills, Support, Goal, etc.
Have you ever wished you were dead or wished you could go to sleep and not wake up?
Prior Mental Health/AoD Treatment
Previous or Current Diagnosis
Medical Problems
Medical Problem Checklist    Check All that Apply
  Yes/No How long have you had this?
Diabetes
Headaches
GASTROINTESTINAL Problems (Nausea or abdominal distress, Reflux, Irritable Bowel Syndrome, Constipation, Diarrhea, GERD)
LOW OR DECREASED ENERGY/FATIGUE
Fibromayalgia/Muscle Pain
CHRONIC PHYSICAL PAIN
Cardiac Problems (high blood pressure, heart attack/angina)
NEUROLOGICAL PROBLEMS (I.E. FITS, SEIZURES, EPILEPSY, MIGRAINES, Stroke, TBI)
Hepatitis/Jaundice
Tuberculosis
AIDS/HIV
Gastric Bypass Surgery
Dental Health Concerns
Visual Health Concerns
Hearing Concerns
Allergies
Respiratory problems (i.e. asthma, COPD, emphysema)
Physical injuries or problems (i.e. back injury, limb fracture or injury)
Skin conditions
Pregnancy
Obesity
Sleep Problems
Is there any other information regarding your medical history that we should know about?
Family history of any medical conditions and clients relationship to that family member.    Medical, Mental health and/or Drugs & Alcohol issues
Tobacco Use
Are you interested in stopping smoking?
Has client had any of the following symptoms in the past 60 days?
Ankle Swelling   Bedwetting   Blood in Stool  
Breathing Difficulty   Chest Pain   Confusion  
Consciousness Loss   Constipation   Coughing  
Cramps   Diarrhea   Dizziness  
Falling   Gait Unsteadiness   Hair Change  
Hearing Loss   Lightheadedness   Memory Problems  
Mole/Wart Changes   Muscle Weakness   Nervousness  
Nose Bleeds   Numbness   Panic Attacks  
Penile Discharge   Seizures   Shakiness  
Sleep problems   Sweats (nights)   Tingling in Arms & Legs  
Tremors   Urination Difficulty   Vaginal Discharge  
Vision Changes   Vomiting   Other  
Allergies    Allergies to food, medicine (Medication allergies or adverse reactions to medications, etc.
In your lifetime, have you ever been hospitalized or treated in an emergency room following an injury to your head or neck? Think about any childhood injuries you remember or were told about.
Do you participate in any sports, exercise programs or activities on a regular basis?
Yes   No    
What are your interests and things you do for fun?
Pregnancy History
How many times have you been pregnant?
Currently pregnant? If no go to bottom and sign form
If yes, expected delivery date?
Receiving prenatal healthcare?
Prenatal healthcare provider?
Form Updates
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