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  • Adult Health History Form

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  • Click "next" to continue with the history form;

    click "save" only if you need to stop and finish later. 

  • Medical History

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    click "save" only if you need to stop and finish later. 

  • Family History



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  • Educational/Employment History


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  • Substance Use History

  • Alcohol Use Questions:

    The Alcohol Use Disorders Identification Test (AUDIT): Self-Report Version, a World Health Organization (WHO)-approved instrument. 

    Because alcohol use can affect your health and can interfere with certain medications and treatments, it is important that we ask some questions about your use of alcohol. Select one box that best describes your answer to each question.

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  • The Alcohol Use Disorders Identification Test (AUDIT) is a 10-item screening tool developed by the World Health Organization (WHO) to assess alcohol consumption, drinking behaviors, and alcohol-related problems. 

    A score of 8 or more is considered to indicate hazardous or harmful alcohol use. The AUDIT has been validated across genders and in a wide range of racial/ethnic groups and is well suited for use in primary care settings. Detailed guidelines about use of the AUDIT have been published by the WHO and are available online:
    http://whqlibdoc.who.int/hq/2001/who_msd_msb_01.6a.pdf

    As for copyright, the AUDIT is a WHO-approved instrument and is in the public domain for use. The key research paper to cite for the AUDIT is: Saunders J.B., Aasland O.G., Babor T.F., de la Fuente J.R. and Grant M. Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative Project on Early Detection of Persons with Harmful Alcohol Consumption II. Addiction 1993; 88:791-804.

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  • Click "next" to continue with the history form;

    click "save" only if you need to stop and finish later. 

  • Mental Health History

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    Thank you for providing this information!

    Click "submit" to send the form to your clinician.

    Only click "save" if you wish to save your information to finish later.

    By submitting this form, you are attesting that all information you provided is true and accurate to the best of your knowledge. 

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