Streamwood Behavioral Healthcare System
Partial (PHP)/Outpatient Services Health History Questionnaire
Page 1 of 2
Name: ______
Age: ______Sex: ______Height: ______Weight: ______
Family Physician: ______Date of Last Physical Exam: ______
In the Past / Current Symptoms / Family History / Not At All / In the Past / Current Symptoms / Family History / Not At AllEyes/Vision Problems / Heart Problems
Ear/Hearing Problems / High Blood Pressure
Ringing of Ears / Blood Disorders
Frequent Headaches / Urinary Tract Infections
Dizziness/Fainting / Incontinence/Urgency
Nasal Congestion / Bowel Problems
Nose Bleeds / Diabetes
Upper Respiratory Infections / Neurological Problems
Coughing up Blood / Seizures
Sore Throat / Bone/Joint Problems
Chronic Cough / Muscle Pains
Asthma/Hayfever / Serious Injuries
TB/TB Contact / Developmental Delays
Speech Problems / Other
Birth Defects
Explain any significant medical conditions as well as any current health problems indicated above:
______
______
Is the client currently under the care of a physician: Yes No
Any restriction in physical activity: Yes No If yes, explain: ______
Are immunizations up to date: Yes No Unknown
If no, explain: ______
ALLERGIES:
Medication Allergies: Yes No If yes, explain/type of reaction: ______
Food allergies: Yes No If yes, explain/type of reaction: ______
Other allergies: Yes No If yes, explain/type of reaction: ______
Streamwood Behavioral Healthcare System
Partial (PHP)/Outpatient Services Health History Questionnaire
Page 2 of 2
List any medical hospitalizations/procedures:
Hospital / Dates / Reason / DiagnosisMEDICATIONS: Not on medication
Current Medications / Dosage & FrequencyPast Medications / Dosage & Frequency
Signature of Person Completing Form/RelationshipDate
To Be Completed by Facility Within the First Three Consecutive Sessions
Is the client currently experiencing pain? Yes No If yes, rating on a scale of 1 to 10______
If the client’s pain is rated as 5 or higher, discussion with parent/guardian regarding options.
Are immunizations up to date: Yes No Unknown
If immunizations are not up to date or unknown, client referred to a physician.
Was the last Physical Exam within the last year? Yes No Unknown
If the last Physical Exam was not within the last year, client referred to a physician.
If the client is referred to a physician for further follow up recommendations, the Outpatient Services Physician Referral Letter is provided to the parent or guardian. A copy of the letter is filed in the client’s medical record.
Outpatient Services Physician Referral Letter provided to parent or guardian.
______Outpatient Services Provider Signature Date/Time
Revised: 6/19/02, 1/04, 11/10, 9/14 Health History Questionnaire Form 6-02