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Phone (OK to call? Yes/No)
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Work (OK to call? Yes/No)
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Student
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Please list other persons living with you
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1. Name
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Relationship
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2. Name
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Relationship
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3. Name
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Relationship
|
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4. Name
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Relationship
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5. Name
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Relationship
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Primary Care Physician Name
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Address
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City, State, Zip
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How were you referred to us
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May we thank your referral source
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Please describe your reason(s) for seeking treatment at this time
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Was there an event that made these issues or problems surface
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If yes, please describe
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Personal Medical History
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Do you have an allergy to food/medication?
|
If yes please describe
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Prescription medications that you currently use/including name/dosage/frequency/doctor
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Hospitalization from past medical/surgical illnesses, including hospital name/dates/procedure
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When was your last physical examination, include date, doctor’s name, and specific findings
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Are you currently being treated for any medical conditions
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If yes, please describe
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Please circle any of the following that apply to you
• • •
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Please briefly describe each selected options
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Have you ever abused drugs or alcohol to your knowledge
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If yes, please describe
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Inpatient/Outpatient
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Provider Name
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First Seen
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Last Seen
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Medication Type & Disease
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Lifestyle/Habits
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Alcohol (type/amount/days)
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Amount Currently Using
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Most Ever Used/Consumed
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Caffeinated Soft Drinks (amount/days)
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Amount Currently Using
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Most Ever Used/Consumed
|
|
Cigarettes/Cigars/Marijuana(type/amount/days)
|
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Amount Currently Using
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Most Ever Used/Consumed
|
|
Drugs (type/amount/days)
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Amount Currently Using
|
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Most Ever Used/Consumed
|
Energy Drinks (amount/days)
|
|
Amount Currently Using
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Most Ever Used/Consumed
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Exercise
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Frequency
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Hobbies
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Frequency
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School/Work (hr/wk)
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Frequency
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|
Family Medical History
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Has anyone in your family had a serious mental illness?
|
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If yes, please describe
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Has anyone in your family a psychiatric (nervous or mental) illness?
|
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If yes, please describe
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Has anyone in your family had a had a substance abuse problem?
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If yes, please describe
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Support Systems
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A. Do you feel like you have any support systems? (family, friends, organizations)
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B. Who do you turn to for support? (emotional or financial)
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C. Have you told them about your situation? How have they responded?
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D. What has your family’s response to your situation been?
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Legal Representative/Guardian Name
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