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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:
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Zip Code :
Phone No:
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?
Have you ever wished you were dead or wished you could go to sleep and not wake up?
Yes
No
Problem Checklist
Check All that Apply
Yes/No
How often do you have this problem?
How long have you had this problem?
Comments
Addiction (Drugs & Alcohol)
Yes
No
Addiction (Gambling/Porn/Sex)
Yes
No
Anger/Aggression
Yes
No
Anxiety
Yes
No
Panic Attacks
Yes
No
Depression
Yes
No
Flashbacks
Yes
No
Grief
Yes
No
Guilt
Yes
No
Hopelessness
Yes
No
Hyperactivity/ADD
Yes
No
Inattention/Easily Distracted
Yes
No
Impulsive
Yes
No
Irritability
Yes
No
Low Self Esteem
Yes
No
Mood Swings
Yes
No
BiPolar
Yes
No
Oppositional Behaviors
Yes
No
Paranoia
Yes
No
reckless, risk taking or self-destructive behaviors
Yes
No
Schizophrenia
Yes
No
Traumatic Stress (Past or Current)
Yes
No
Discrimination due to race, ethnicity, and/or LGBTQ+ status
Yes
No
Food insecurity (problems with having enough to eat)
Yes
No
Housing insecurity/issues
Yes
No
Transportation issues/lack of transportation
Yes
No
Employment issues
Yes
No
Any repetitive thoughts, images, or impulses that you can't get out of your mind?
Yes
No
DO YOU THINK ABOUT ANYTHING REPEATEDLY THAT CAUSES ANXIETY?
Yes
No
Do you engage in any repetitive or ritualized behaviors ?
Yes
No
Do you feel like any of these behaviors don't make sense or take up more time than is necessary?
Yes
No
Nutrition/Eating Problems
Yes
No
Do you make yourself Sick because you feel uncomfortably full?
Yes
No
Do you worry you have lost Control over how much you eat?
Yes
No
Have you recently lost more than 14 lbs in a 3month period?
Yes
No
Do you believe yourself to be Fat when others say you are too thin?
Yes
No
Would you say Food dominates your life?
Yes
No
Prior Mental Health/AoD Treatment
Yes
No
Past responses to treatment both positive and negative:
Reason? Focus? Type of therapy? Length? Why did you stop? Results? What did you learn that was helpful? Anything not addressed? Likes and dislikes of prior therapy?
Previous or Current Diagnosis
List current medications (prescriptions, over the counter, herbals, vitamin/mineral/dietary supplements) including name, dosages, frequency and route.
Past Psychiatric Medications
Please list medication and reason it was stopped
Medical Problems
Primary Care Physician
Medical Problem Checklist
Check All that Apply
Yes/No
How long have you had this?
Diabetes
Yes
No
Headaches
Yes
No
Nausea or abdominal distress
Yes
No
LOW OR DECREASED ENERGY/FATIGUE
Yes
No
Fibromayalgia/Muscle Pain
Yes
No
CHRONIC PHYSICAL PAIN
Yes
No
Cardiac or respiratory problems (i.e. asthma, emphysema, high blood pressure, heart attack/angina)
Yes
No
Epilepsy/Seizures
Yes
No
Hepatitis/Jaundice
Yes
No
Tuberculosis
Yes
No
AIDS/HIV
Yes
No
Gastric Bypass Surgery
Yes
No
Dental Health Concerns
Yes
No
Visual Health Concerns
Yes
No
Hearing Concerns
Yes
No
Allergies
Yes
No
Gastrointestinal/hepatic problems (i.e. liver disease, pancreatitis, gastric ulcer, reflux)
Yes
No
Physical injuries or problems (i.e. back injury, limb fracture or injury)
Yes
No
Neurological problems (i.e. fits, seizures, epilepsy, migraines)
Yes
No
Skin conditions
Yes
No
Pregnancy
Yes
No
Sleep Problems
Yes
No
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.
Tobacco Use
Yes
No
Are you interested in stopping smoking?
Yes
No
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.
Yes
No
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?
Do you use complementary health approaches?
Ex's: natural products, such as dietary supplements, • Mind and body practices, such as acupuncture, massage therapy, meditation, movement therapies, yoga, and relaxation techniques. • Homeopathy, naturopathy, and traditional healers.
Yes
No
Pregnancy History
How many times have you been pregnant?
Currently pregnant? If no go to bottom and sign form
Yes
No
If yes, expected delivery date?
Receiving prenatal healthcare?
Yes
No
Prenatal healthcare provider?
Form Updates
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