Center For Individual & Family Therapy A Christian Counseling Center Family Forms Page 6
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6FAMILY MEDICAL HISTORY
Please indicate with an “X” how often you experience any of the following:
NEVER
SELDOM SOMETIMES
OFTEN
NAME OF FAMILY MEMBER
Loss of Appetite
Lack of sleep
Back Pain
Asthma
Headaches
Phobias (Fears)
Nausea
Allergies
Nervousness
Loss of temper
Fatigue
Depression
Constipation
Diarrhea
Over-eating
Mood swings
Smoking
Amount
Alcohol Intake
Amount
Self-injury
Hearing/Seeing things
that are not there
FAMILY MEDICATION AND TREATMENT HISTORY
DAILY
FREQUENTLY OCCASIONALLY NEVER
NAME OF FAMILY MEMBER
Appetite Suppressant s
Aspirin
Sedatives/Tranquilizers
Sleeping Pills
Stimulants
Vitamins
Other (please specify)
Please list current medications
FAMILY TREATMENT/THERAPY HISTORY
Have you ever had any previous counseling or psychotherapy? Y
N
If YES, please list from most recent:
PROBLEM
DATES
THERAPIST & LOCATION
Was Therapy Successful?
Have you ever attempted suicide? Y
N
If YES, when?
If YES, method used:
Were you ever hospitalized for psychiatric reasons? Y
N
If Yes, when?
Length of hospital stay
FAMILY OF ORIGIN INFORMATION
Husband/Partner
Wife/Partner
Marital Stat
Marital Stat
Age
Occupation
Alive/Deceased
Age
Occupation
Alive/Deceased
Father
Mother
Siblings
Briefly describe the relationship you have/had with your family of origin (husband/male)
Briefly describe the relationship you have/had with your family of origin (wife/female)
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Parent category: Medical