Medical History form

Date

Last Name

First Name

Middle Name

Age

Sex

MaleFemale

How did you hear about Psychiatric Wellness Center?

Describe briefly your present symptoms:

Please list your primary care physician and any specialists that you are currently seeing: (include their name & location)

Have you had psychotherapy or are you currently in psychotherapy? (include where, when & therapist’s name)

Medical Hospitalizations (include where, when, & for what reason):

Psychiatric Hospitalizations (include where, when, & for what reason):

CURRENT MEDICATIONS
Drug allergies: NoYes
Please list any medications that you are now taking. Include non-prescription medications & vitamins or supplements:
S.No.	Name of drug	How long did you take it?	Please list side effects:
1
2
3
4

PAST MEDICAL HISTORY
Do you now or have you ever had:
DiabetesHigh blood pressureHigh cholesterolHypothyroidismGoiterCancerLeukemiaPsoriasisAnginaHeart problems	Heart murmurPneumoniaPulmonary embolismAsthmaEmphysemaStrokeEpilepsy (seizures)CataractsKidney diseaseKidney stones	Crohn’s diseaseColitisAnemiaJaundiceHepatitisStomach or peptic ulcerRheumatic feverTuberculosisHIV/AIDS
Other medical conditions (please list):

PERSONAL HISTORY
Were there problems with your birth? (specify)	Where were your born & raised?
What is your highest education? High schoolSome collegeCollege graduate Advanced degree	Marital status: Never marriedMarriedDivorcedSeparatedWidowedPartnered/significant other
What is your current or past occupation?	Are you currently working?: YesNo
Hours/week	If not, are you retireddisabledsick leave?
Do you receive disability or SSI? YesNo	If yes, for what disability & how long?
Have you ever had legal problems? (specify)	Religion:

PERSONAL HISTORY

Were there problems with your birth? (specify)

Where were your born & raised?

What is your highest education?

High schoolSome collegeCollege graduate Advanced degree

Marital status:

Never marriedMarriedDivorcedSeparatedWidowedPartnered/significant other

What is your current or past occupation?

Are you currently working?:

YesNo

Hours/week

If not, are you

retireddisabledsick leave?

Do you receive disability or SSI?

YesNo

If yes, for what disability & how long?

Have you ever had legal problems? (specify)

Religion:

SYSTEMS REVIEW
In the past month, have you had any of the following problems?
GENERAL Recent weight gainRecent weight lossFatigueWeaknessFeversweats	NERVOUS SYSTEM HeadachesDizzinessFainting or loss of consciousnessNumbness or tinglingMemory loss	PSYCHIATRIC DepressionExcessive worriesDifficulty falling asleepDifficulty staying asleepDifficulties with sexual arousalPoor appetiteFood cravingsFrequent cryingSensitivityThoughts of suicide / attemptsStressIrritabilityPoor concentrationRacing thoughtsHallucinationsRapid speechGuilty thoughtsParanoiaMood swingsAnxietyRisky behavior
MUSCLE/JOINTS/BONES NumbnessJoint painMuscle weaknessJoint swelling	STOMACH AND INTESTINES NauseaHeartburnStomach painVomitingYellow jaundiceIncreasing constipationPersistent diarrheaBlood in stoolsBlack stools
EARS Ringing in earsLoss of hearing	BLOOD AnemiaClots
THROAT Frequent sore throatsHoarsenessDifficulty in swallowingPain in jaw	SKIN RednessRashNodules/bumpsHair lossColor changes of hands or feet	EYES PainRednessLoss of visionDouble or blurred visionDryness
HEART AND LUNGS Chest painPalpitationsShortness of breathFaintingSwollen legs or feetCough	KIDNEY/URINE/BLADDER Frequent or painful urinationBlood in urine	Women Only: Abnormal Pap smearIrregular periodsBleeding between periodsPMS

SYSTEMS REVIEW

In the past month, have you had any of the following problems?

GENERAL

Recent weight gainRecent weight lossFatigueWeaknessFeversweats

NERVOUS SYSTEM

HeadachesDizzinessFainting or loss of consciousnessNumbness or tinglingMemory loss

PSYCHIATRIC

DepressionExcessive worriesDifficulty falling asleepDifficulty staying asleepDifficulties with sexual arousalPoor appetiteFood cravingsFrequent cryingSensitivityThoughts of suicide / attemptsStressIrritabilityPoor concentrationRacing thoughtsHallucinationsRapid speechGuilty thoughtsParanoiaMood swingsAnxietyRisky behavior

MUSCLE/JOINTS/BONES

NumbnessJoint painMuscle weaknessJoint swelling

STOMACH AND INTESTINES

NauseaHeartburnStomach painVomitingYellow jaundiceIncreasing constipationPersistent diarrheaBlood in stoolsBlack stools

EARS

Ringing in earsLoss of hearing

BLOOD

AnemiaClots

THROAT

Frequent sore throatsHoarsenessDifficulty in swallowingPain in jaw

SKIN

RednessRashNodules/bumpsHair lossColor changes of hands or feet

EYES

PainRednessLoss of visionDouble or blurred visionDryness

HEART AND LUNGS

Chest painPalpitationsShortness of breathFaintingSwollen legs or feetCough

KIDNEY/URINE/BLADDER

Frequent or painful urinationBlood in urine

Women Only:

Abnormal Pap smearIrregular periodsBleeding between periodsPMS

WOMENS REPRODUCTIVE HISTORY:
Age of first period	# Pregnancies:	# Miscarriages:
Abortions	Have you reached menopause? YesNo	Do you have regular periods? YesNo

WOMENS REPRODUCTIVE HISTORY:

Age of first period

# Pregnancies:

# Miscarriages:

Abortions

Have you reached menopause?

YesNo

Do you have regular periods?

YesNo

SUBSTANCE USE
DRUG CATEGORY (circle each substance used)	Age when you first used this:	How much & how often did you use this?	How many years did you use this?	When did you last use this?	Do you currentlyuse this?
ALCOHOL:					YesNo
CANNABIS: Marijuana, oil, lotion					YesNo
STIMULANTS: Cocaine, crack					YesNo
STIMULANTS: Methamphetamine—speed					YesNo
AMPHETAMINES/OTHER STIMULANTS: Ritalin, Dexedrine					YesNo
BENZODIAZEPINES/TRANQUILIZERS: Valium, Librium, Halcion, Xanax, Diazepam, Ativan, Klonopin					YesNo
SEDATIVES/HYPNOTICS/BARBITURATES:Phenobarbital					YesNo
HEROIN					YesNo
STREET OR ILLICIT METHADONE					YesNo
OTHER OPIOIDS: Tylenol #2 & #3, 282’S, 292’S, Percodan, Percocet, Opium, Morphine, Demerol, Dilaudid					YesNo
HALLUCINOGENS: LSD, PCP, STP, MDA, DAT, mescaline, peyote, mushrooms, ecstasy (MDMA), nitrous oxide					YesNo
INHALANTS:Glue, gasoline, aerosols, paint thinner					YesNo
OTHER					YesNo