Admission Assessment Update Form
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2Rosecrance is a behavioral health care organization that is bound by strict state and
federal privacy and confidentiality regulations. Please fax this form. Do not email.
Admission Assessment Update
Please fill out both sides of this questionnaire as completely and accurately as possible.
Name
Date of birth __________________
_____________________________________________
Please update any personal information that has changed since your assessment with us
_____ No _____ Yes:___________________________________________
Phone number/address has changed
_____ No _____ Yes:___________________________________________
Marital status has changed
_____ No _____ Yes:___________________________________________
Employer or employment status has changed
_____ No _____ Yes:___________________________________________
Funding source for treatment has changed
Health and health-related information (outpatient only)
_____ No _____ Yes:___________________________________________
Current or recent (since assessment) illnesses
_____ No _____ Yes:___________________________________________
Are you currently pregnant?
_____ No _____ Yes (if yes, please provide information below)
Are you currently taking any medications?
Name of medication
Dosage
Reason for taking
Prescribing physician
__________________________
_____________ ________________________________ __________________________________________
__________________________
_____________ ________________________________ __________________________________________
__________________________
_____________ ________________________________ __________________________________________
__________________________
_____________ ________________________________ __________________________________________
__________________________
_____________ ________________________________ __________________________________________
_____ No _____ Yes:___________________________________________
Do you believe your medications are helping you?
_____ No _____ Yes:___________________________________________
Do you take herbal supplements or vitamins?
_____ No _____ Yes:___________________________________________
Have you used shared needles?
_____ No _____ Yes:___________________________________________
Do you currently use tobacco?
_____ No _____ Yes:___________________________________________
Are you interested in quitting tobacco use?
_____ No _____ Yes:___________________________________________
Do you exercise regularly?
Have you ever been hospitalized for psychiatric care?
_____ No _____ Yes: When?____________ Where? _________________
If yes, please describe ___________________________________________________________________________________________________
_____ No _____ Yes: When?____________ Who? _________________
Have you ever seen a psychiatrist?
Reason: _______________________________________________________
_____ No _____ Yes: (please explain) ____________________________
Are you currently seeing a psychiatrist? (need signed release)
_______________________________________________________________
_____ No _____ Yes: (please explain) ____________________________
Have you ever had suicidal thoughts?
_______________________________________________________________
_____ No _____ Yes: (please explain) ____________________________
Have you ever thought of harming others?
_______________________________________________________________
Who is your current physician, and what is his/her phone number and address? (need signed release)
Physician: ___________________________________ Phone: ____________________ Address: _______________________________________
In case of emergency, whom should we contact? (need signed release)
Name: ___________________________________ Phone: ____________________ Relationship to you: ________________________________
When did you last use ANY substance? _____________________________________________________________________________________
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