S M D WD

Name / Age / Occupation / Marital Status (Circle one) / Date

Describe any health concerns:

______

HAVE YOU EVER HAD OR CURRENTLY HAVE: MEDICATIONS: List all medications, vitamins or supplements you are now taking

Eye disease, injury, impaired sight...... noyesincluding over the counter medications, and include amount and frequency.

Ear disease, injury, impaired hearing...... noyes

Any trouble with nose, sinuses, mouth, throat...... noyes

Loss of consciousness/ Fainting Spells...... noyes

Convulsions or seizures...... noyes

Paralysis...... noyes

Dizziness...... noyes

Frequent or severe headaches...... noyes

Depression or anxiety...... noyesFAMILY HISTORY- Has your mother, father, spouse, children or other

Memory loss...... noyesclose family member ever had:

Auditory hallucinations (hearing voices) ...... noyes- Hepatitis...... noyes

Visual hallucinations (seeing things that were not really there)..noyes- Tuberculosis...... noyes

Enrolled in an outpatient rehabilitation program for substance abusenoyes- HIV disease...... noyes

Any significant financial problems related to spending

inappropriately or gambling...... noyesSURGERIES...... noyes

Thought about committing suicide...... noyesIf so, please list: ______

Attempts to commit suicide...... noyes______

Struck or hit or hurt anyone when angry or physically or ______

emotionally incapacitated...... noyes

Easily angered or impatient...... noyesHOSPITALIZATIONS:...... noyes

Any learning disorders or difficulties...... noyesPlease list: ______

Enlarged glands or lumps...... noyes______

Enlarged thyroid or goiter...... noyes______

Skin changes or changes in moles...... noyes- Admitted to a long health care facility, nursing home or rehabilitation

Chronic or frequent cough...... noyes center...... noyes

Sputum production or any blood in sputum...... noyes- Lived in a homeless shelter, refugee camp, jail or prison...... noyes

Chest pain or chest pressure...... noyes- Admitted to the hospital for psychiatric or psychological

Night sweats...... noyesmedical problems...... noyes

Shortness of breath...... noyes

Palpitation or Fluttering heart...... noyesAlcohol Use

Swelling of hands,feet or ankles...... noyesHow many days a week do you have alcohol______

Extreme tiredness or weakness...... noyesHow many drinks per day do you have when you drink ______

Kidney diseases or stones...... noyesWhat is the most drink you have had in one day in the past five years______

Bladder disease...... noyesHave you ever tried to cut back on how much alcohol you drink....noyes

Albumin, sugar, pus, etc. in urine...... noyesHave you ever been told by others that you drink too much or have to

Frequency of or difficulty or pain with passing urine...... noyescut back on your drinking...... noyes

Abnormal thirst...... noyesHave you ever felt guilty about your drinking...... noyes

Stomach trouble or ulcer...... noyesDid you ever feel the desire or need to drink alcohol in the morning.noyes

Indigestion...... noyesHave you been accused or charged with driving while intoxicated

Liver or gall bladder disease...... noyeswith alcohol or any substance...... noyes

Jaundice or hepatitis...... noyesAny history of recreational drug use...... noyes

Colitis or other bowel disease...... noyesIf so please list recreational drugs used and when last used ______

Rectal bleeding...... noyes______

Constipation or diarrhea...... noyes

Any recent change in your appetite no yes Sexual orientation: Heterosexual Homosexual Bisexual

Any unintentional weight loss...... noyesHave you ever experienced any physical or sexual abuse...... noyes

Elevated blood pressure or hypertension...... noyesHow many sexual partners have you had in your life______

Elevated cholesterol...... noyesHave you always used a barrier form of contraception like male or

Elevated blood sugar or diabetes...... noyesfemale condoms...... noyes

Heart attacks...... noyes

Heart problems ( arrhythmias, valve disease)...... noyesHave you been intimate with prostitute or IV drug abusers...... noyes

Strokes or mini strokes...... noyesHave you had more than one sexual partner in

Pneumonia...... noyes- the last year?...... no yes

Asthma or any chronic lung disease...... noyes- in the last five years?...... noyes

Cancer...... noyesHave you or your sexual partner had any transfusions

If yes, what type:______between 1978 and 1985?...... noyes

Bone or joint disease (arthritis, osteoporosis)...... noyesHave you ever shared needles to self administer IV drugs...... noyes

Exposure to tuberculosis or positive sign test...... noyes

Any open sores or lesions in the genital area...... noyesHave you been charged with any criminal or civil act?...... noyes

Swollen glands in your groin area...... noyesHave you ever had a driver’s license revoked?...... noyes

Gonorrhea, syphilis, herpes or genital warts...... noyesHave you ever had a professional license revoked or fired from

Aching or swelling muscles or joints...... noyesa job for cause...... noyes

Concussions or head injuries...... noyesHave you ever gotten a pension or disability payment from an employer

Knocked unconscious...... noyesor governmental agency?...... noyes