Only Health History Form

Health History Form
Must be completed 24 hours prior to your first appointment or it will need to be rescheduled.

* Indicates required field

Name *

First

Last

What brings you in for treatment? *

HISTORY OF PRESENT ILLNESS

Do you experience any of the following anxiety symptoms (select all that apply)? *

Do you have a trauma history as defined by an experienced or witnessed traumatic event, series of events or set of circumstances? An individual may experience this as an emotionally or physically harmful or life-threatening event. Examples include natural disasters, serious accidents, terrorist acts, war/combat, rape/sexual assault, historical trauma, intimate partner violence, child abuse and bullying, *

Yes No Unsure

Add any additional information here about your trauma, that you would like to share *

Do you currently experience any of these behaviors and/or feelings (select all that apply)? *

Self harm (without intent to die) Passive death wish (wishing you were dead or wouldn't wake up in the morning) Thoughts of suicide Thoughts of physically hurting others (without intent) No thoughts of self injurious behaviors, passive death wish, suicidal thoughts or thoughts of hurting others Other

Do you currently feel safe and that you will not harm yourself or anyone else before your appointment? *

Yes

IF YOU ANSWERED NO, PLEASE STOP COMPLETING THIS FORM AND EITHER CALL 911 OR REPORT TO YOUR NEAREST EMERGENCY ROOM

Have you ever experienced any of the following symptoms (select all that apply)? *

hallucinations (auditory, visual, tactile, olfactory) people are putting thoughts in your head people are taking thoughts out of your head others can read your thoughts TV, radio, computer is directly talking about you or to you delusions (thoughts that are very real to you, but not supported by reality) No symptoms of psychosis

In the past month, have you exhibited any of these other symptoms or behaviors (select all that apply) *

Please Comments or Symptoms *

PAST PSYCHIATRIC HISTORY

Do you have a current.... *

Therapist Primary Care Provider Neither

Have you ever been hospitalized for psychiatric reasons? *

Yes No Other

If yes, please briefly explain *

Have you experienced any of these behaviors and/or feelings in the past (choose all that apply? *

Self harm (without intent to die) Passive death wish (wishing you were dead or wouldn't wake up in the morning) Thoughts of suicide History of suicide attempt(s) No history of self injurious behaviors, passive death wish, suicidal thoughts or attempts

Do you have a history of violence towards others? *

Yes No Other

If yes, please explain *

Please list the name, dose and frequency of your psychiatric medications (if none, please write none) *

MEDICAL HISTORY

Do you have any medication allergies? *

Yes No Known Drug Allergies

If yes, please list your medication allergies *

Please enter your height *

Please enter your weight *

Please list any medical problems *

Please list any major surgeries or write none. *

Please list the name, dose and frequency of your somatic (non-psychiatric) medications (if none, please state) *

Substance Use History (if you select NEVER/RARELY you do not need to answer the optional questions).

How often do you drink caffeine? *

If you drink caffeine, how much do you drink? *

How often do you smoke cigarettes? *

If you smoke cigarettes or used to smoke cigarettes, how long have you/did you smoke for (number of years)? *

Do you use cannabis (marijuana)? *

Yes No

Are you interested in a medical marijuana card? *

Yes No Maybe

How often do you drink alcohol? *

If you drink alcohol or used to drink alcohol, how much do you/did you drink (12oz beer= 5oz wine = 1.5oz liquor)? *

How often do you use cocaine, crack or other stimulants (other than prescribed)? *

If you use cocaine/crack/stimulants or used to use cocaine/crack/stimulants, how much do you/did you use in a single sitting? *

How often do you use heroin or opioids (other than prescribed)? *

If you use heroin/opioids or used to use heroin/opioids, how much do you/did you use in a single sitting? *

How often do you use hallucinogens (e.g. MDMA, molly, shrooms, psylocibin, acid, LCD, etc)? *

Have you ever received substance abuse treatment? *

Yes No

FAMILY HISTORY

Does anyone in your immediate biological family have any of the following? *

A psychiatric condition A substance use problem A suicide completion No known family history of suicide or mental health/substance abuse problems

If yes, please elaborate *

Do any of the following apply? *

A history of child abuse As a child, were you ever involved with child protective services (CPS) Was in foster care No known history of child abuse, CPS involvement or foster care as a child

SOCIAL HISTORY

What is your relationship status? *

How many children do you have (if none, put 0)? *

Are you pregnant or could possible be pregnant? If at any point you think you might be pregnant or are trying to get pregnant, please alert the prescriber. *

Yes No N/A

What is your current living situation? *

What is your highest level of education? *

Do any of the following apply? *

Received special education Diagnosed with a learning disability Diagnosed with an intellectual disability No known history of special education, learning disability or intellectual disability

What is your employment status? *

Are you currently or have you ever been in the military? *

Yes No

Do any of the following legal situations apply (select all that apply) *

Been arrested Been convicted of a crime Been incarcerated No legal history

If there is any other information that you think is pertinent for me to know, please explain. *

​Health History

Health History FormMust be completed 24 hours prior to your first appointment or it will need to be rescheduled.

HISTORY OF PRESENT ILLNESS

​IF YOU ANSWERED NO, PLEASE STOP COMPLETING THIS FORM AND EITHER CALL 911 OR REPORT TO YOUR NEAREST EMERGENCY ROOM

PAST PSYCHIATRIC HISTORY

MEDICAL HISTORY

​Substance Use History (if you select NEVER/RARELY you do not need to answer the optional questions).

FAMILY HISTORY

SOCIAL HISTORY

Health History

Health History Form
Must be completed 24 hours prior to your first appointment or it will need to be rescheduled.

IF YOU ANSWERED NO, PLEASE STOP COMPLETING THIS FORM AND EITHER CALL 911 OR REPORT TO YOUR NEAREST EMERGENCY ROOM

Substance Use History (if you select NEVER/RARELY you do not need to answer the optional questions).