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MEDICAL HISTORY
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Medical History
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PSYCHIATRIC HISTORY
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Psychiatric History
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Has patient attempted suicide in the past?
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Number of Past Suicide Attempts
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Time Elapsed Since Most Recent Suicide Attempt? [X weeks/months/years]
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Has patient ever been hospitalized for psychiatric illness?
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Number of Past Hospitalizations
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Time Elapsed Since Most Recent Hospitalization [X weeks/months/years]
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Psychiatric Problems
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Psychiatric Problems [Additional Comments]
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SOCIAL HISTORY
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MARRIAGE & SEXUAL
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Sexual Orientation(s)
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Client Marriage History
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Patient has Children
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Number of Children
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TOBACCO USE
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Does Patient Have History of Tobacco Use?
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Tobacco -- Frequency of Use
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ALCOHOL USE
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Does Patient Have History of Alcohol Use?
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Alcohol -- Frequency of Use
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ILLICIT SUBSTANCE USE
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Does Patient Have History of Illicit Substance Use?
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Substance (#1)
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Substance (#1) -- Name
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Substance (#1) -- Frequency of Use
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Substance (#1) -- Time Elapsed Since Last Encounter [X days/weeks/months/years]
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Substance (#2)
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Substance (#2) -- Name
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Substance (#2) -- Frequency of Use
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Substance (#2) -- Time Elapsed Since Last Encounter [X days/weeks/months/years]
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Substance (#3)
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Substance (#3) -- Name
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Substance (#3) -- Frequency of Use
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Substance (#3) -- Time Elapsed Since Last Encounter [X days/weeks/months/years]
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Substance (#4)
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Substance (#4) -- Name
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Substance (#4) -- Frequency of Use
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Substance (#4) -- Time Elapsed Since Last Encounter [X days/weeks/months/years]
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Substance (#5)
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Substance (#5) -- Name
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Substance (#5) -- Frequency of Use
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Substance (#5) -- Time Elapsed Since Last Encounter [X days/weeks/months/years]
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WORK HISTORY
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Is Patient Currently Employed?
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Current Employment -- Title
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Current Employment -- Description
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Current Employment -- Duration [X days/weeks/months/years]
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FAMILY HISTORY
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Disease (#1)
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Disease (#1) -- Affected Family Members
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Disease (#1) -- Name
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Disease (#2)
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Disease (#2) -- Affected Family Members
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Disease (#2) -- Name
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Disease (#3)
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Disease (#3) -- Affected Family Members
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Disease (#3) -- Name
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Disease (#4)
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Disease (#4) -- Affected Family Members
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Disease (#4) -- Name
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Disease (#5)
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Disease (#5) -- Affected Family Members
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Disease (#5) -- Name
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