Adult Health History Form

Medical History
Describe any early developmental delays experienced in walking, talking, potty training, etc.
Date of last last visit to primary care physician or other medical doctor?*

MonthDayYear
If unsure, give approximate date.
Describe if there were any concerns at that time:
If available, please upload (or provide a photo of) the most recent medical summary from the last visit (some insurance companies are requesting this for prior approval):

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Medical record photo:
Are there any hearing or vision issues? *
If Yes, how are they corrected (with glasses, contact lenses, hearing aids, etc.)?
Describe any history of hospitalizations for general medical reasons:
(i.e., when and why did they occur, for how long, any lasting concerns?)
Briefly describe any surgeries that have been required:
(i.e., when and why did they occur, any lasting concerns?)
Briefly describe any chronic illnesses or concerns:
(i.e., diabetes, asthma, etc.)
Check all of the known allergies:

Pollen/SeasonalMedication - specify belowFood - specify belowOther substance - specify belowOther
What medications (non-psychiatric) are CURRENTLY being taken?
Provide names, dosages, and condition they treat if applicable.
Briefly describe any prior head injuries (if applicable):
When did the injury occur, any concussion or medical treatment needed, any lasting concerns, etc.?
Have there been any appetite problems or changes in weight in the past several months?
If Yes, briefly describe:
Have there been any sleep problems or nightmares in the past several months?
If Yes, briefly describe:
(i.e., How often are there problems or nightmares - nightly, weekly, month? What are the nightmares about? Is there trouble falling or staying asleep?)
Click "next" to continue with the history form;

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

Mental Health History
Have you EVER received a mental health diagnosis in the past?*
Briefly indicate which diagnoses were given and any additional information you have.
(i.e., What were the diagnoses, when were they given, and by whom)
Have you ever seen a psychiatrist for psychiatric medication as a child or adult?
If Yes, what was the name of psychiatrist? When was the last appointment?
Are you CURRENTLY taking psychiatric medications?*
(i.e., for ADHD, depression, anxiety, etc.)
If Yes, what are the name(s) and dosages of your current medication(s):
Describe any changes you have noticed since starting your current psychiatric medications.
(i.e., more focused, more calm, less sad, less worried, less irritable, more or less sleepy or tired, less or more appetite, etc.)
List any negative reactions or problems associated with psychiatric medications you may have had taken in the past.
(i.e., Problems with insurance, not effective, caused problem side effects, etc)
Have you ever had a psychological evaluation?*
If Yes, what was the name of psychologist, and when was the last evaluation?
If available, please upload the prior psychological evaluation for review. This could also be faxed or emailed to the clinician (some insurance companies are requesting this to be reviewed for prior approval):

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Have you ever been admitted to a psychiatric hospital?
If Yes, please list date(s) and name(s) of hospital(s):
Are you CURRENTLY receiving therapy or counseling?*

If Yes, select all that currently apply:

	Service Type	Provider or Agency	Date Started	Frequency	For what issues?
Individual
Group
Family
Other

Have you received therapy or counseling in the PAST?

Describe any PAST therapy or counseling you recieved?

	Service Type	Provider or Agency	Date Started	Date Stopped	How many sessions (approx.)?	Why discontinued?
Individual
Group
Family
Other

Describe any "other" forms of therapy you recieved. You may also use this space to comment on any prior treatment history:
Describe any history of self-harming behaviors, suicide attempts, or suicidal ideation. If applies, when was the last time?
If you are experiencing suicidal ideation at this moment, please call 911 or visit your nearest hospital for an evaluation. This form submission is not intended to communicate a medical emergency, as the response time may be delayed.
If there is any family history of mental health concerns or diagnoses, please describe:
Are there any additional comments or concerns that were not included above that you believe are important for your clinician to know about?
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.
Should be Empty:

	Never	Monthly or less	2-4 times a month	2-3 times a week	4 or more times a week
3. How often do you have six or more drinks on one occasion?
4. How often during the last year have you found that you were not able to stop drinking once you had started?
5. How often during the last year have you failed to do what was normally expected of you because of drinking?
6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?
7. How often during the last year have you had a feeling of guilt or remorse after drinking?
8. How often during the last year have you been unable to remember what happened the night before because of your drinking?

	no use	less than 1x /month	1 to 3x /month	1 to 2x /week	4 to 6x /week	daily
Cannabis (marijuana, hash oil, pot, weed)
Stimulants (cocaine, crack, methamphetamine, meth, ice, crank, amphetamines)
Benzodiazepines/Tranquilizers (valium, Librium, Xanax, Diazepam, roofies, downers)
Heroin or other opioids (Tylenol #2 or #3, Percodan, Percocet, Opium, Morphine, Demerol, Dilaudid)
Hallucinogens (LSD, PCP, mescaline, peyote, mushrooms, ketamine, ecstasy (MDMA)
Inhalants (glue, gasoline, butane, aerosols, paint thinner, poppers)
Steroids (unprescribed use of Deca-Durabolin, Durabolin, Equipoise, Winstrol, Anadrol, Oxandrin, roids)
Illegal or unprescribed use of prescription drugs
Nicotine (tobacco, vape, smokeless)
Over the counter medication(s) (for recreational use or abuse)

Adult Health History Form

Medical History

Family History

Educational/Employment History

Substance Use History

Mental Health History