Intake Form - Counseling Life Wellness Page 2
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1
2
3Medical History Questionnaire
2
NAME:
DOB:
8.
Do you use tobacco?
No
Yes #
per day.
Never smoked.
Former smoker: yr started
yr stopped
9.
Do you consume caffeine?
No
Yes, how many cups/cans?
per day
10. In total, how much fluid do you drink per day? (total oz or # cups)
11a. Do you consume alcohol?
No
Yes, how often?
1-2x/wk
3-4x/week
5+x/week. # drinks per day
Date last used
Amount
Age of first use
Never used
11b. Do you use marijuana?
No
Yes, how often?
1-2x/wk
3-4x/week
5+x/week. Amount per day
Date last used
Amount
Age of first use
Never used
11c. Do you use other substances (drugs)
No
Yes, how often?
1-2x/wk
3-4x/week
5+x/week
Date last used
Amount
Age of first use
Never used
11d. Do you engage in behaviors such as gambling, compulsive spending or eating
Last time
How often
Age of onset
Never
12. Have you recently experienced any of the following (past 90 days)?
Dizziness
No
Yes, when
Unusual sweats or chills
No
Yes, when
No
Yes, when
Seizures
Persistent cough
No
Yes, when
Shortness of breath
No
Yes, when
Passing out
No
Yes, when
No
Yes, when
Persistent nausea / vomiting
Self-induced vomiting
No
Yes, when
Frequent or prolonged diarrhea / constipation
No
Yes, when
No
Yes, when
Weight loss / gain
Urinary discomfort
No
Yes, when
Severe dry mouth
No
Yes, when
Ear infections
No
Yes, when
No
Yes, when
Respiratory infections
Persistent sore throat
No
Yes, when
Excessive use of laxatives
No
Yes, when
No
Yes, when
Inappropriate bed wetting
Inappropriate defecation (bowel elimination)
No
Yes, when
Facial or muscle twitching / jerking
No
Yes, when
Dry skin
No
Yes, when
No
Yes, when
Hair loss
Sexually Transmitted Diseases
No
Yes, when
What
Bleeding anywhere (e.g. mouth, urine, stool)
No
Yes, when
Swelling anywhere (e.g. legs, ankles, feet)
No
Yes, when
Problem with sleeping
No
Yes, indicate more or less sleep
Past Surgeries
No
Yes, please describe below:
Date
Description
Rev 2016 1127
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