Has anyone in your family aid to abuse alcohol and drugs ?  If yes who? _______________________________________

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List everyone living in client's home - Minor clients include parents & sibling outside of home
  Name
 DOB
 Age
 Relationship
 Education
 Occupation
1
            
2
            
3
            
4
            
5
            
6
            
MEDICAL HISTORY
 Physical Health List client & family members chronic illnesses  - complete separate line for each illness
Who
 Diagnosis
 Medication
 Dose
 Date Started
 Doctor
           
           
           
           
           
           
Emotional Health  list client & family members who have emotional illnesses with medication and provider information
Who
 Diagnosis
 Medication
 Dose
 Date Started
 Doctor
           
           
           
           
           
           
Chemicals Used by Client and family
Who
 What used
 Current Usage
 Past Usage
 Date Started
         
         
         
         
         
List Client & family symptoms Indicate how often symptoms are experience > O= Often  S= Sometimes  N= Never
Symptoms
 Who
 How Often
 Date started
 Who
 How often
 Date Started
Suicidal thoughts
            
Suicidal Plan  ____ attempts ___
            
Purposely hurt self
            
Purposely hurt someone else
            
Accused of Sexual abuse
            
Anxiety____  Panic attacks____
            
Hyper  __  Manic _____
            
Thinks someone out to get them
            
Depressed loss of interest in life
            
Sadness ___  Crying __
            
Irritable  crabby
            
Isolated withdrawn
            
Hears or sees things no one else
does
            
Overly self critical
            
Overly critical of others
            
Excessively loud or talkative
            
Eats non nutritive substances
            
Pick at body or pulls hair
            
Anger Outburst
            
Easily frustrated
            
Excessive involvement in
pleasurable activities
            
Rapid change in moods
            
Night mares
            
Go with out sleep
            
Sleep excessively how much?
            
Eat too little ___  to much___
stomach pain ______
            
Vomiting ___ Binging____
            
Act before thinking
            
Learning difficulty
            
Forgetful
            
Problem concentrating
            
Always moving
            
Weight loss _____  gain____
            
Blames other for their behaviors
            
Refused to do as asked
            
Physically   aggressive
            
Verbally aggressive
            
Bullies, intimidates,threatens
            
Feel excessively guilty
            
Been stalked or stalked anyone
            
Been in relationship with
someone your afraid of
            
Regressed behaviors
            
Repetitive behaviors
            
Rituals
            
Behaviors tried to stop couldn't
            
Difficulty moving from one
activity to another
            
Upsetting memories
            
Nervous ___   worry ___
            
Make poor eye contact
            
Dishonest
            
Feel frightened
            
Feeling numb
            
Repeats same words frequently
            
People take advantage of me
            
Avoid social situation
            
Inappropriate sexual activities
            
Overly sensitive to sound, light,
touch
            
             
Emotional Health Please list names & contact  info for any other previous or current mental health professionals that provided services
to  you    _____________________________________________________________________________________________________

___________________________________________________________________________________________________________
Client Name ______________________________________     Date__________________

Family History  Marital Status:   single___  Married___  Divorced___ Co-habitation___ Other _____________

How long for above status _________   Number of marriages  ___________________________________________

# children ____________________________________________________________________________________