2 - Clinical History

Please list members of your present household.

Full Name

Age

Gender

Relationship

Comments

Please list members of your household growing up.

Full Name

Age

Gender

Relationship

Comments

Section 6B: Treatment History
Psychologist/Therapist/Counselors
Dates
Psychiatric Provider (MD, NP, PA)
Dates
Inpatient and IOP
Hospitalizations, day treatment, substance rehab
Dates
Family history of mental health issues, suicide, drug dependency or alcohol problems
Include parents, grandparents, siblings, aunts, uncles, and cousins.
If yes, please explain
Family history of psychiatric hospitalizations?
Include parents, grandparents, siblings, aunts, uncles, and cousins.
If yes, please explain

Please fully list for all substances used.

Substance

Age First Use

Age Last Use

Heaviest Use (Age)

Heaviest Use (Amt)

Current Use

Method of Use

Have you ever felt that you should cut down on your drinking or use of drugs?
Have people ever annoyed you by criticizing your drinking or use of drugs?
Have you ever felt bad or guilty about your drinking or use of drugs?
Have you ever had a drink or used drugs first thing in the morning to stead your nerves or to get you over a hang-over? (An eye opener)
Have you ever used any drug by injection?

Section 8: Physical Health (Almost done...)
Current medical conditions
Allergies
Drugs, food, environment
Current sleep habits/issues
Current nutritional habits/issues
Eating disorder history
Current medication prescriber?
List primary care as well if different from prescriber
Office address and phone number
Current presciber/primary care.

List all medications or supplements you are currently taking (including psychiatric, medical, and over the counter)

Drug

Dose

Start Date

Condition Treated

Please list past psychiatric medications and how you responded to them.

Drug

Condition Treated

Response

Clinical History Form