Intake Form - Counseling Life Wellness

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NAME:
DOB:
MEDICAL HISTORY QUESTIONNAIRE
1. Are you currently taking any medications (prescriptions, over the counter vitamins, homeopathic or naturopathic
remedies, traditional or alternative medicine remedies, herbs)?
No, go to question 2.
Yes, answer questions 1(a) – 1(e) below
Identify the medications that you are currently taking for medical or behavioral health concerns and the reason for taking the
1(a)
including OTC vitamins, minerals, dietary and herbal supplements.
medications below,
Name of Medication or supplement
Dose
Reason for Taking
Prescribed and supervised by
Have any of your medications been changed in the last 30 days?
No
Yes, list the medications and what changes have
been made:
2.
Are you allergic to any medications?
No
Yes, which ones?
3.
Do you have any other allergies?
No
Yes, describe them:
4.
When was the last time you saw your primary care physician/dentist?
Reason for visit?
5.
Do you have any history of head injury with concussion or loss of consciousness?
No
Yes, how was it treated?
Include date(s) and description
6.
Are you currently pregnant?
No
Yes
Unsure
How many children do you have?
None
Number of live births
None
Abortions
None
Miscarriages / stillborn
None
7.
Are there any medical problems that you are currently receiving treatment for?
No, go to question 8.
Yes, answer 7(a) and 7(b) below
Describe below what current medical problems you have and what type of treatment you are currently receiving:
7(a)
Medical Problem
Type of Treatment Receiving
Does your current medical condition(s) create chronic pain?
No (If no, go to question 8)
Yes: Please circle average
7(b)
0
1
2
3
4
5
No pain
Moderate
Worst possible
Pain
pain
Location (e.g. headache):
Quality (e.g. burning, sharp, throbbing, dull):
When does it occur?
How long does it last?
How does it affect your functioning (e.g. can’t sit, walk, work out)?

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