166 Main Street, Winona, MN 55987
HISTORY FORM
Thanks for taking the time to completely fill out this form as it will help us to better understand you and your situation. The information you provide here is confidential and will only be shared with your clinician.
IDENTIFYING INFORMATIONName / Last / First / Middle
Former Name(s)
General / Date of Birth / Age / Social Security Number / Gender
Telephone / Home: / Cell: / Work:
Address / Street
City / County / State / Zip
Race: / American Indian/Alaska Native Asian White
Native Hawaiian or Pacific Islander Other Race African American
Ethnicity / Not of Hispanic Origin Hispanic Origin regardless of race Mexican Cuban
Puerto Rican Other Specific Hispanic
Living Status / Homeless/Shelter Foster Care/Foster Home Residential Care Crisis Residence
Institutional setting Jail/correction facility Private residence-independent living
Private residence dependent living Other residential status Unknown
Tribal Member / Not Enrolled Bois-Forte Fond-du –Lac Grand Portage
Leech Lake Lower Sioux Mille-Lacs Band Prairie Island Red Lake
Shakopee White Earth Other Unknown
Marital Status / Divorced Domestic Partner Single Married Separated Single Widowed
Tobacco Use / User Non User
Language / English Spanish Hmong Mandarin Other ______
Military Status/
MHIS Combat Status / No Yes, no combat Yes, served in combat zone Yes, combat unknown
Served From: To: Deployment From: To:______
Employment / Full-Time 32hrs/week
Part-Time <32hrs/week
Looking for work/Unemployed / Place of Employment: ______
Occupation: ______
Clerical Labor Professional Unknown
Not in the Labor Force / Homemaker Sheltered Employment Student Retired Disabled
Hospital patient/resident of other institution Other (ex: volunteer)
Highest Level of Education
Current Education Enrollment Status / 1st grade 2nd grade 3rd grade 4th grade 5th grade 6th grade 7th grade
8th grade 9th grade 10th grade 11th grade H.S 12th/GED Vocation/Tech School
1st year college 2nd year college 3rd year college 4th year college
Graduate/Professional/ Master’s Degree( law, medical )
Enrolled Not Enrolled
Legal Status / Voluntary-Self Voluntary-Other (guardian, parent) Court Hold Emergency Hold
Civil commitment MI Civil Commitment MI/CD Civil Commitment MI/DD
Civil Commitment MI & D Civil Commitment-sexual Civil Commitment-other
Criminal Commitment Provisional Discharge Unknown
HEALTHCARE PROVIDER INFORMATION
Do you have a regular physician?
/ ¨ Yes¨ No / Name Phone
Address
Do you want a summary sent to this person (as listed above)? ¨ Yes ¨ No
Do you have a regular dentist?
/ ¨ Yes¨ No / Name Phone
Address
Do you currently access any other agencies and/or services?
(Case Manager; guardian, ARMHS providers, public health, home health) / ¨ Yes¨ No / Name Phone
Address
Do you want a summary sent to this person (as listed above)? ¨ Yes ¨ No
Were you referred here by someone? / ¨ Yes
¨ No / Who sent you? ______
Address: ______
Do you want a summary sent to this person? ¨ Yes ¨ No
What are the major concerns, issues or symptoms that bring you to our Center?
List any previous mental health therapy you have had.
GOALS OF THERAPY
What goals do you have for your treatment?
ALLERGIES
Have you ever had allergic reactions to medications: hives, skin rash, breathing problems or other? / ¨ Yes ¨ No If Yes, please list below:
Name of Medication Describe Allergic Reaction
______
______
Are there medications, other than those you are allergic to, you would prefer not to take due to unpleasant side effects?
¨ Yes ¨ No If Yes, please specify which medication and what the unpleasant side-effect was:
GENERAL MEDICAL
When did you last have a medical checkup? / Date
Have you ever had any of the following problems? / Seizure
Head Injury
High Blood Pressure
Heart Trouble
Kidney Problems
Other: / Yes No
Yes No
Yes No
Yes No
Yes No / Diabetes
Asthma
Thyroid Problems
Liver Problems
High Cholesterol / Yes No
Yes No
Yes No
Yes No
Yes No
Have you ever had any surgery or medical hospitalizations? / Date List:
Have you ever been hospitalized for mental health reasons? / Date List:
Are you currently taking any prescription medication? / ¨ Yes ¨ No
Name of Medication Dose How often taken
Are there other medications that you have used recently? / ¨ Yes ¨ No If Yes, please list below:
Name & location of pharmacy
Have you taken steroid or cortisone-type drugs within the last year? ¨ Yes ¨ No
Have you taken any over-the-counter meds, herbal remedies or supplements in the last month? Yes No
Please list below: ______
Have you ever been on medications (other than those listed above) for "nerves", depression, anxiety, or other psychological issues? ¨ Yes ¨ No
If Yes, please list:
If sexually active, do you use any contraceptives or protection from sexually transmitted diseases (STD's)? Please specify.
FAMILY RELATIONSHIPS
Relationship status:
(check as many as apply) / ¨ N/A (Child) ¨ Single ¨ Married ¨ Widow ¨ Divorced
¨ In a significant relationship
¨ Separated from partner ______Date ______
If you are in a relationship, please complete. / Partner's Name:
How long in relationship: ______
Please list all people with whom you currently live with. / Name(s)
/ Age(s) / Relationship to person receiving services
Please list parents, brothers sisters, minors, or adult children who are not currently living in your home. / Name(s)
/ Age(s) / Relationship to person receiving services
Are you adopted? / ¨ Yes ¨ No
Please describe any family information (current/past) that might be helpful:
· Mental health issues
· Medical issues
· Deaths in family
· Divorces, step-parents
· Any type of abuse/trauma
Are you currently religiously affiliated? / ¨ Yes ¨ No ¨ Decline If Yes, what religion?
Former religious affiliation? / ¨ Yes ¨ No ¨ Decline If Yes, what religion?
CHEMICAL and ALCOHOL USE
Drug Use
(Check your drug of choice, if applicable) / Age of First Use / Most Recent Pattern of use and Duration
How much you use, how often, and do you need more or less to get the same effect? / Date of last use and time, if needed / Method of use
(oral, smoked, snort, IV, etc)
ALCOHOL
CAFFEINE
MARIJUANA/
HASHISH
COCAINE/CRACK
METH/ AMPHETAMINES
HEROIN
SYNTHETICS
INHALANTS
BENZODIAZEPINES
HALLUCINOGENS
BARBITURATES/
SEDATIVES/
HYPNOTICS
OVER-THE-COUNTER MEDICATIONS
NICOTINE
OTHER
Do you use greater amounts of alcohol/other drugs to feel intoxicated or achieve the desired effect? Yes No
Or use the same amount and get less of an effect? Yes No
Have you ever been to detox?
Yes No / When was the first time? / How many times since then? / Date of most recent detox?
Withdrawal symptoms; Have you had any of the following withdrawal symptoms?
Symptom / Past 12 months / Recent
(past 30 days) / Symptom / Past 12 months / Recent
(past 30 days)
SWEATING (RAPID PULSE) / NAUSEA/VOMITING
SHAKY/JITTERY/TREMORS / DIZZINES
UNABLE TO SLEEP / SEIZURES
AGITATION / DIARRHEA
HEADACHE / DIMINISHEDAPPETITE
FATIGUE/EXTREMELY TIRED / HALLUCINATIONS
SAD/DEPRESSED FEELING / FEVER
MUSCLE ACHES / UNABLE TO EAT
VIVID/UNPLEASANT / PSYCHOSIS
DREAMS / CONFUSED/DISRUPTED
IRRITABILITY / SPEECH
SENSITIVITY TO NOISE / ANXIETY/WORRIED
HIGH BLOOD PRESSURE
Are you seriously considering addressing your alcohol and/or drug use within the next six months? Yes No
Are you planning to stop or reduce your alcohol and/or drug use in the next 30 days? Yes No
(Perhaps taking small steps to do so)?
Are you now actively remaining abstinent from your use of alcohol and/or drugs? Yes No
Have you ever felt you ought to cut down on your drinking or drug use? Yes No
Have you ever had people annoy you by criticizing your drinking or drug use? Yes No
Have you ever felt bad or guilty about your drinking or drug use? Yes No
Have you ever had a drink or used drugs as an eye opener first thing in the morning
to steady your nerves, to get rid of a hangover, or to get the day started? Yes No
Reasons for drinking/drug use (Check answers that apply)
Like the feeling / To relax or unwind / Partner encourages use
Trying to forget problems / Makes it easier to talk with people / Most friends drink or use
To cope with stress / To cope with family problems / To cope with family problems
To relieve physical pain / To cope with anxiety / To cope with depression
Other (specify)
Have you ever been to an AA/NA or any other 12-Step Support Group?
Do you have a sponsor? / Yes No If yes, date of last meeting ______
Yes No
Any history of suicide in your family? Yes No Or, someone close to you? Yes No
Are thoughts of suicide occurring when under the influence? Yes No
Legal history: List current/recent history of any legal problems related to substance use.
______
Signature of Person Completing Form Relationship to client Date
Rev 08/2016
P: Form Templates/General Forms/HVMHC General Forms/History Forms
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