Parental Permission To Treat A Minor Page 7
ADVERTISEMENT
1
2
3
4
5
6
7
8Medical History Form
Kanawha Pastoral Counseling Center
Client Name _________________________________
16 Leon Sullivan Way, Suite 300
Charleston, WV 25301
Date ______/________/_______
304-346-9689
Family History:
Where were you born? __________________ Where did you grow up? __________________
Number of siblings _____________ Your birth order ___________ (youngest, oldest, etc.)
Do you have any family members who have been in counseling or hospitalized for psychiatric reasons?
Do you have any family members who have struggled with addictions?
Do you have any family members who have struggled with hurting themselves or others?
Medical/Surgical History:
Do you have a regular Doctor? ______ Name ________________________ Phone ______________
Date of Last checkup ______________________________________________________
KPCC encourages its clients to have a regular medical exam at least once a year. Medical issues
can sometimes cause mental, emotional or relational distress, and so it is important to rule these
out as not being a factor in what has brought you to counseling.
If you do not have a regular doctor, we urge you to get one. If you do not have insurance or a
medical card, you may qualify for free medical service at WV HealthRight.
Please check any illness you currently have or had in the past.
_____ Diabetes
_____ High Blood Pressure _____ Lung Disease
_____ Sex Trans Disease
_____ Rheumatic Fever
_____ Low Blood Pressure
_____ Cancer
_____ Arthritis
_____ Heart Disease
_____ Jaundice
_____ Kidney Disorder
_____ Thyroid Disease
_____ Pneumonia
_____ Hepatitis
_____ Head Injuries
_____ Anemia
_____ TB
_____ Cirrhosis
_____ Injuries
_____ Ulcer
_____ Colitis
_____ Bone Disorder
_____ Muscular Disorder
_____ Nerve Disorder
_____ Seizures
___________________________________________________________________________
_____ Other:
(over please)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business