Medical HistoryPage 1 of 4

Client Name: ______Date: ______

Date of Birth: ______Age: ______

MEDICAL / PERSONAL HISTORY

•What are you seeking treatment for? ______

______

•PLEASE LIST ANY PREVIOUS HOSPITALIZATIONS:

YEAR / CITY / ILLNESS / HOW LONG / HOSPITAL

•List any serious illnesses during the past 5 years: ______

______

______

LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING:

MEDICATION / DOSAGE / #TIMES DAILY

•CHECK ANY OF THE FOLLOWING SYMPTOMS OR CONDITIONS YOU HAVE HAD IN YOUR LIFETIME:

Blurred VisionDiabetesSmoker’s Cough

Double VisionKidney or Urine InfectionHearing Loss

Severe HeadachesBlood in UrineSwollen Ankles

BlackoutBack PainBruise Easily

SeizureAllergiesWeakness in Arms or Legs

Loss of ConsciousnessHemorrhoidsVenereal Disease (VD)

Dizzy SpellsHepatitisReaction to Medications

Head InjuryJaundice (yellow skin)Blood Transfusions

Vomited BloodShortness of BreathBroken Bones

Blood in Bowel MovementChest PainsSinus or Frequent Colds

Excessive Blood LossHeart AttacksTuberculosis

Stomach Pain Pneumonia

•FAMILY: Has anyone in your family (parents, brothers, sisters, aunts, uncles, cousins, and children) had any of the following? Please check:

Kidney DiseaseTumorsMental Illness

Heart DiseaseDiabetesEpilepsy

CancerTuberculosisNervous Disorders

•PLEASE CHECK WHICH SYMPTOMS OR CONDITIONS YOU ARE EXPERIENCING NOW OR IN THE PAST.

- Circle those you are currently taking medication for.

PresentPastPresentPast

Insomnia (difficulty sleeping)Depression

No appetiteOvereating

Alcohol AbuseMood Swings

Alcoholism Excessive Worries

Crying SpellsFears or Phobias

HallucinationsConfusion

Difficulty ConcentratingFrequent Loss of Temper

Compulsions Weight Changes

Extreme NervousnessWeight Loss/Gain

Can’t keep a jobFingernail Biting

Frequent employment changeLack of Confidence

Fire setting past age 8Blaming others frequently

IndecisivenessLow Self-Esteem

Frequent AccidentsSexual Problems

NightmaresExtreme Loneliness

PalpitationsBowel Disturbances

Feeling TenseUnable to relax

Don’t like weekendsCan’t make friends

Financial problemsFainting Spells

FatigueFeeling Panicky

Suicidal IdeationInferiority Feelings

PresentPastPresentPast

Memory ProblemsIrritability

Drug AbuseTaking Drugs

Bedwetting past age 6Tremors

Shy with PeopleCan’t make decisions

Home conditions stressfulConcentration difficulties

Unable to have a good timeSleeping too much

List all previous psychological or psychiatric counseling or treatment:

•When:______Where:______

Reason:______

•When:______Where:______

Reason:______

•When:______Where:______

Reason:______

Have you ever attempted suicide? YesNoWhen? ______

Have you ever overdosed from a drug?YesNoWhen? ______

Has anyone in your immediate family (spouse, parents, children, brothers, sisters) ever had any psychological or psychiatric treatment or counseling, or been hospitalized for mental, emotional or nervous disorders?

YESorNO

If yes, who? ______

What do you know about it? ______

FAMILY ORIGIN:

Relation / Alive or Deceased? / Current Age / Occupation / Cause of Death / Your Age at Death
Father
Mother
Sibling
Sibling
Sibling
Sibling

•Are there any other members of the family about whom information regarding illness is relevant?______

DRUG AND ALCOHOL USE:

•How much of the following substances do you use on a weekly basis?

PRESENTPAST

Glasses of Wine______

Cans or bottles of beer______

Shots of hard liquor______

Marijuana______

Cocaine______

Pills (upper / downer)______

Crystal Meth______

Heroin______

Other – Please describe______

Client Signature: ______

Medical History Form was Reveiwed by: ______Date: ______