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Adult Intake
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Past Medical / Surgical History
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Any active medical conditions?
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Other active medical conditions:
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HIV status:
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HIV last test date:
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PCP contact information
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Last visit date:
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Immunization up to date?
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Any surgery?
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Surgery other:
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Past Psychiatric Hx
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Prior Inpatient Psych
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Prior Outpatient Psych
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Prior SA
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Self - Harm?
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Prior Detox/Rehab
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Other psych hx :
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Family History
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Family History :
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Family SA or completed suicide?
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Social History
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Childhood abuse?
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Other Trauma
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Emotional Support
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Social Hx :
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Occupation and work history :
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Substance History
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Substance Abuse
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Substance comments :
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Do you drink caffeine beverages
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Caffeine Amount Daily
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Do you drink alcoholic beverages
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Alcoholic Beverages Amount
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Alcoholic Beverages
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Do you use tobacco now
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Tobacco in what form
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Tobacco Amount
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Ever used illicit drugs
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Do you now
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Substance Abuse Additional :
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LEGAL HISTORY (Explain if Necess
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Ever Arrested
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Ever Convicted
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Current Legal Problems
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Comments :
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