History Form

History Form
Date*
MM slash DD slash YYYY
Name*
First Middle Last
Birthdate
MM slash DD slash YYYY
Age*
Sex*
- Male
- Female
How did you hear about this clinic?
Describe briefly your present symptoms:
Please list the names of other practitioners you have seen for this problem:
Psychiatric Hospitalizations (include where, when, & for what reason):
- Have you ever had ECT?
- Have you had psychotherapy?
CURRENT MEDICATIONS
Drug allergies*
- NO
- YES
To what?
Please list any medications that you are now taking. Include non-prescription medications & vitamins or supplements:
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PAST MEDICAL HISTORY
Do you now or have you ever had:
- Diabetes
- High blood pressure
- High cholesterol
- Hypothyroidism
- Goiter
- Cancer
Cancer (type)*
- Leukemia
- Psoriasis
- Angina
- Heart problems
- Heart murmur
- Pneumonia
- Pulmonary embolism
- Asthma
- Emphysema
- Stroke
- Epilepsy (seizures)
- Cataracts
- Kidney disease
- Kidney stones
- Crohn’s disease
- Colitis
- Anemia
- Jaundice
- Hepatitis
- Stomach or peptic ulcer
- Rheumatic fever
- Tuberculosis
- HIV/AIDS
Other medical conditions (please list):
PERSONAL HISTORY

Were there problems with your

birth? (specify)

Where were your born & raised?
What is your highest education?
- High school
- Some college
- College graduate
- Advanced degree
Marital status
- Never married
- Married
- Divorced
- Separated
- Widowed
- Partnered/significant other
What is your current or past occupation?
Are you currently working?
- Yes
- No
Hours/week*
If not, are you
- retired
- disabled
- sick leave?
Do you receive disability or SSI?
- Yes
- No
If yes, for what disability & how long?*

Have you ever had legal problems? (specify)
Religion*
FAMILY HISTORY
IF LIVING IF DECEASED
Father
Age (s)*
Health & Psychiatric*
Age(s) at death*
Cause*
Mother
Age (s)*
Health & Psychiatric*
Age(s) at death*
Cause*
Siblings
Age (s)*
Health & Psychiatric*
Age(s) at death*
Cause*
Children
Age (s)*
Health & Psychiatric*
Age(s) at death*
Cause*
EXTENDED FAMILY PSYCHIATRIC PROBLEMS PAST & PRESENT:*
Maternal Relatives:*
Paternal Relatives:*
SYSTEMS REVIEW
In the past month, have you had any of the following problems?
GENERAL
- Recent weight gain
- Recent weight loss
- Fatigue
- Weakness
- Fever
- Night sweats
Recent weight gain; how much*
Recent weight loss: how much*
NERVOUS SYSTEM
- Headaches
- Dizziness
- Fainting or loss of consciousness
- Numbness or tingling
- Memory loss
MUSCLE/JOINTS/BONES
- Numbness
- Joint pain
- Muscle weakness
- Joint swelling
Where?
STOMACH AND INTESTINES
- Nausea
- Heartburn
- Stomach pain
- Vomiting
- Yellow jaundice
- Increasing constipation
- Persistent diarrhea
- Blood in stools
- Black stools
SKIN
- Redness
- Rash
- Nodules/bumps
- Hair loss
- Color changes of hands or feet
EARS
- Ringing in ears
- Loss of hearing
EYES
- Pain
- Redness
- Loss of vision
- Double or blurred vision
- Dryness
THROAT
- Frequent sore throats
- Hoarseness
- Difficulty in swallowing
- Pain in jaw
BLOOD
- Anemia
- Clots
HEART AND LUNGS
- Chest pain
- Palpitations
- Shortness of breath
- Fainting
- Swollen legs or feet
- Cough
WOMEN ONLY
- Abnormal Pap smear
- Irregular periods
- Bleeding between periods
- PMS
KIDNEY/URINE/BLADDER
- Frequent or painful urination
- Blood in urine
PSYCHIATRIC
- Depression
- Excessive worries
- Difficulty falling asleep
- Difficulty staying asleep
- Difficulties with sexual arousal
- Poor appetite
- Food cravings
- Frequent crying
- Sensitivity
- Thoughts of suicide / attempts
- Stress
- Irritability
- Poor concentration
- Racing thoughts
- Hallucinations
- Rapid speech
- Guilty thoughts
- Paranoia
- Mood swings
- Anxiety
- Risky behavior
OTHER PROBLEMS:*
WOMENS REPRODUCTIVE HISTORY:*
Age of first period:
Pregnancies:
Miscarriages:
Abortions:
Have you reached menopause?
- Yes
- No
At what age?
Do you have regular periods?
- Yes
- No
SUBSTANCE USE

DRUG CATEGORY
ALCOHOL
(circle each substance used)
Do you currently use alcohol?*
- Yes
- No
Age when you first used alcohol :
How much & how often did you use alcohol?*
How many years did you use alcohol?*
When did you last use alcohol ?*
CANNABIS:
Marijuana, hashish, hash oil
Do you currently use cannabis ?*
- Yes
- No
Age when you first used cannabis :*
How much & how often did you use cannabis?*
How many years did you use cannabis?*
When did you last use cannabis ?*
STIMULANTS:
Cocaine, crack
Do you currently use stimulants ?*
- Yes
- No
Age when you first used stimulants:*
How much & how often did you use stimulants?*
How many years did you use stimulants?*
When did you last use stimulants ?*
STIMULANTS:
Methamphetamine—speed, ice, crank
Do you currently use stimulants ?*
- Yes
- No
Age when you first used stimulants:*
How much & how often did you use stimulants?*
How many years did you use stimulants?*
When did you last use stimulants?*
AMPHETAMINES/OTHER STIMULANTS:
Ritalin, Benzedrine, Dexedrine
Do you currently use amphetamines/other stimulants?*
- Yes
- No
Age when you first used amphetamines/other stimulants:*
How much & how often did you use amphetamines/other stimulants?*
How many years did you use amphetamines/other stimulants?*
When did you last use amphetamines/other stimulants?*
BENZODIAZEPINES/TRANQUILIZERS:
Valium, Librium, Halcion, Xanax, Diazepam,
“Roofies”
Do you currently use benzodiazepines/tranqulizers?*
- Yes
- No
Age when you first used benzodiazepines/tranqulizers:*
How much & how often did you use benzodiazepines/tranqulizers?*
How many years did you use benzodiazepines/tranqulizers?*
When did you last use benzodiazepines/tranqulizers?*
SEDATIVES/HYPNOTICS/ BARBITURATES:
Amytal, Seconal, Dalmane, Quaalude,
Phenobarbital
Do you currently use sedatives/hypnotics/barbiturates?*
- Yes
- No
Age when you first used sedatives/hypnotics/barbiturates:*
How much & how often did you use sedatives/hypnotics/barbiturates?*
How many years did you use sedatives/hypnotics/barbiturates?*
When did you last use sedatives/hypnotics/barbiturates?*
HEROIN
Do you currently use heroin?*
- Yes
- No
Age when you first used heroin:*
How much & how often did you use heroin?*
How many years did you use heroin?*
When did you last use heroin?*
STREET OR ILLICIT METHADONE
Do you currently use street or illicit methadone?*
- Yes
- No
Age when you first used street or illicit methadone:*
How much & how often did you use street or illicit methadone?*
How many years did you use street or illicit methadone?*
When did you last use street or illicit methadone?*
OTHER OPIOIDS:
Tylenol #2 & #3, 282’S, 292’S, Percodan,
Percocet, Opium, Morphine, Demerol,
Dilaudid
Do you currently use other opioids?*
- Yes
- No
Age when you first used other opioids:*
How much & how often did you use other opioids?*
How many years did you use other opioids?*
When did you last use other opioids?*
HALLUCINOGENS:
LSD, PCP, STP, MDA, DAT, mescaline,
peyote, mushrooms, ecstasy (MDMA),
nitrous oxide
Do you currently use hallucinogens?*
- Yes
- No
Age when you first used hallucinogens:*
How much & how often did you use hallucinogens?*
How many years did you use hallucinogens?*
When did you last use hallucinogens?*
INHALANTS:
Glue, gasoline, aerosols, paint thinner,
poppers, rush, locker room
Do you currently use inhalants?*
- Yes
- No
Age when you first used inhalants:*
How much & how often did you use inhalants?*
How many years did you use inhalants?*
When did you last use inhalants?*
Do you currently use other?*
- Yes
- No
OTHER: (specify)
Age when you first used other:*
How much & how often did you use other?*
How many years did you use other?*
When did you last use other?*
Download The Form

History Form

History Form

CURRENT MEDICATIONS

PAST MEDICAL HISTORY

FAMILY HISTORY

Father

Mother

Siblings

Children

SYSTEMS REVIEW

SUBSTANCE USE

DRUG CATEGORY

ALCOHOL

CANNABIS:

STIMULANTS:

STIMULANTS:

AMPHETAMINES/OTHER STIMULANTS:

BENZODIAZEPINES/TRANQUILIZERS:

SEDATIVES/HYPNOTICS/ BARBITURATES:

HEROIN

STREET OR ILLICIT METHADONE

OTHER OPIOIDS:

HALLUCINOGENS:

INHALANTS:

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