CLIENT MEDICAL HISTORY/INTAKE WB

Serenity Counseling & Wellness Center

CLIENT MEDICAL HISTORY/INTAKE
Client Name*

First NameLast Name
Client Gender*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client Date of Birth*

MonthDayYear
Phone Number*
Please enter a valid phone number.
Client E-Mail*
example@example.com
Parent/Guardian Name (If Applicable)

First NameLast Name
Highest Level of Education Completed*
Employment*
How many jobs have you had?*
What is the longest time you have spent at one job?*
Do you have any current pending legal issues?*

YesNo
What pending legal issues do you currently have?*
If none please write 'none'.
Anger Issues?*

YesNo
How is self esteem?*
How do you see yourself?
How is hygiene? (Example: how often do you shower, change your clothes, brush your teeth, etc.)*
Client Medical History

Please fill out every question, if no answer or unknown then write 'none' or 'unknown'.
Please List Client Allergies*
If none please write none.
Energy; How are your energy levels throughout the day?*

High; I feel like I have too much energy throughout the day.Appropriate; I feel like I have the right amount of energy throughout the day.Varies; I feel like it depends on the day, sometimes I have high/regular amount of energy and others I feel low.Low; I feel like I do not have enough energy throughout the day.
Have you ever experienced suicidal thoughts?*

No, I have not experienced suicidal thoughts.In the past I have experienced suicidal thoughts, but not currently.Yes, I currently have suicidal thoughts.
If you have suicidal thoughts, how often do you have them? (If you do not have suicidal thoughts, please select the 'Never' option)*

NeverRarelyOccasionallyOften
Have you ever had self-injurious behaviors? (Example: Cutting, Burning, etc.)*

NeverPreviouslyCurrently
Have you ever been part of an outpatient program?*

YesNo
If yes, please list what programs below:*
If none please write 'none'.
Please List Client Hospitalization History*
Medical or Psychiatric; If none write none.
Please List Client Current Medications*
If none then please write none.
Depression: On a scale of 0-10 (0 being no depression, 10 being severe depression) what would you rate your depression at today? *
Anxiety: On a scale of 0-10 (0 being no anxiety, 10 being severe anxiety) what would you rate your anxiety today? *
Include other comments regarding your Medical History*
Client's Habits

Please answer honestly so that we may provide the best treatment for you.
Sleeping Habits; How do you sleep at night?*

Good; I get a full 7-9 hours uninterrupted.Okay; I get a decent nights rest with minimum interruption.Bad; I do not get enough sleep at night. (toss&turn often, trouble falling/staying asleep)
Appetite; How are your eating habits?*

Good; I am hungry at appropriate times and eat appropriate meal portions.Okay; For the most part I eat at appropriate times and appropriate meal portions.Not so good; I sometimes eat too much or too little.Bad; I always eat far too much or far too little.
Exercise; How many days do you exercise per week?*

Never1-2 days3-4 days5+ days
Eating following a diet*

I have a loose dietI have a strict dietI don't have a diet plan
Alcohol Consumption*

I don't drink alcohol1-2 glasses/day3-4 glasses/day5+ glasses/day1-2 glasses/week3-4 glasses/week5+ glasses/week
Caffeine Consumption*

I don't use caffeine1-2 cups/day3-4 cups/day5+ cups/day
Do you smoke cigarettes?*

No0-1 pack/day1-2 packs/day2+ packs/day0-1 pack/week1-2 packs/week2+ packs/week
Do you vape?*

Noyes
Have you ever used an illicit substance or abused any medication?*

NoYes
How often do you use illicit substances or abuse medication?*

I never have used illicit substances or abused medication.I have used illicit substances/abused medication in the past, but no longer do.I have experimented with illicit substances/experimented with medications before.I occasionally use illicit substances/abuse medication.I often use illicit substances/abuse medication.
Please indicate if you have ever used any of the below. (Select all that apply)*

CaffeineAlcoholCigarettes/Nicotine/TobaccoMarijuana/CannabisStimulants or "Uppers" (Example: Cocaine, Ritalin, Methamphetamine)Anxiolytics/Sedatives/Hypnotics or "Downers" (Example: Barbituates {Secobarbital/Quaaludes}, Benzodiazepines {Valium, Xanax, Rohypnol})Opiates or "Painkillers" (Example: Heroin/Morphine/Methadone/Oxycodone)Hallucinogens (Example: LSD/PCP/Ecstasy)Inhalants/AerosolsSteroidsNone of the above
Do you currently or have you ever struggled with any of the following? (Select all that apply)*

Drug AddictionAlcohol AddictionPorn AddictionGambling AddictionSex AddictionNone of the above apply to meOther
Any Trauma History? (Example: Domestic Violence, Sexual Assault, Fire, Flood, Emotional Abuse, etc.)*

YesNo
You may print this for form and mail it to

Serenity Counseling & Wellness Center

700 W Center St
Unit 8
West Bridgewater, MA. 02739

if you prefer not to submit it electronically.
Should be Empty:

Serenity Counseling & Wellness Center

Client Medical History

Client's Habits