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Psychiatric, Medical, Family and Social History
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CLIENT'S PSYCHIATRIC HISTORY
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Current/Past Psychiatric Diagnoses
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Current/Past Psychiatric Symptoms
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Current/Past Psychiatric/Psychologic Treatments Multi Select
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Current/Past Psychiatric/Psychological Treatments Write in
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CLIENT'S MEDICAL HISTORY
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Medical Conditions
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Any Hx of issues with anesthesia?
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Patient's Surgical Procedures
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Tests, Labs
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Patient's Disability
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Identify Disability
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CLIENT'S FAMILY MEDICAL HISTORY
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Narrative
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CLIENT'S FAMILY PSYCHIATRIC HISTORY
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Narrative
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CLIENT'S DEVELOPMENTAL HISTORY
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Client's Place of Birth
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Client's Family Biological/Adopt
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Client Adopted Age
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Client's # of Moves in Lifetime
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Development
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Development Explain
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Client's Parents Married
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Client Raised by (Parent)
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Client's Siblings (Name(s)/Age(s)
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Client's Family Contact
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Relationship with Family
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SPIRITUAL HISTORY
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Narrative
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CLIENT'S RELATIONSHIP HISTORY
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Client Relationship History
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Client's Children (names and age
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EDUCATIONAL & VOCATIONAL HISTORY
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Completed High School
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High School Comments
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Learning Disabilities/Special Education
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Learning Disabilities/Special Education Comments
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College Training
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College Training Comments
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Vocational Schooling
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Vocational Schooling Comments
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Vocational History
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Current Employment
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Current Employment Duration
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Current Employment (additional info.)
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Past Employment
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Past Employment (additional info)
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Past Employment Duration
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Reason for Leaving
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MILITARY SERVICE
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Military Service
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Military Service Branch
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Military Service Active Duty
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Military - Type of Discharge
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Military - Date of Discharge
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LEGAL HISTORY (Explain if Necessary)
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Ever Arrested
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Current Legal Problems
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Ever Convicted
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Notes:
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SUBSTANCE USE HISTORY
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Have you ever used nicotine products?
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Do you use nicotine products now?
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Nicotine Products, Additional Information
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Nicotine Products: Form/Amount/Frequency
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Do you drink caffeinated beverages?
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Caffeine - Amount/Frequency
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Alcohol History
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Alcoholic Beverages
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Alcoholic Beverages - Additional Information
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Alcoholic Beverages - Amount/Frequency
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Cannabis History
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Cannabis - Form
• • •
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Cannabis - Additional Information
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Cannabis - Amount/Frequency
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Stimulant History
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Stimulants - Form
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Stimulants - Additional Information
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Stimulants - Amount/Frequency
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Methamphetamine History (speed, crystal meth, ice, etc.)
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Methamphetamine - Frequency/Amount
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Inhalants (NO2, glue, gas, paint thinner, etc.)
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Inhalants (Type, Frequency, Amount)
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Sedatives/Hypnotics
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Sedative/Hypnotics - Form
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Sedative/Hypnotics - Additional Information
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Sedative/Hypnotics - Amount/Frequency
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Hallucinogens (LSD, acid, mushrooms, PCP, special K, ecstasy, etc.)
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Hallucinogens - Form
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Hallucinogens - Additional Information
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Hallucinogens - Amount/Frequency
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Opiates - History
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Opiates - Form
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Opiates - Additional Information
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Opiates - Amount/Frequency
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Any experimentation with other illicit substances?
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Other Pertinent Substance Use Information
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Treatment for Addiction
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Treatment for Addiction - When & Where
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TRAUMA & ABUSE HISTORY
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Sexual
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Describe - Duration
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Physical
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Describe - Duration
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Emotional
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Describe - Duration
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Neglect
• • •
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Describe - Duration
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Ever been in an accident
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Seen someone injured or die
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Die or Injured Comments
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Other Pertinent Information re: Traumatic Events
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