Medical History Client First Name First Client Last Name Last Height Weight Age Would you like us to provide you with Advanced Directives training and planning in case of a mental health emergency? Yes No Have you ever seen a Psychiatrist before? Yes No Who did you see? Are you in pain? Yes No Rate your pain level from 1-10 (10 being the greatest)Please check any of the following problems that you currently experience or have experienced: Aches and Pains Allergies Appetite Disturbance Arthritis Asthma Cancer Chemical Imbalance Cavities/Tooth Decay Chronic Fatigue Cirrhosis Crohn’s Disease Chest Pains Dermatology Diabetes Dietary Difficulties Dizziness Dementia Dyspareunia Endometriosis Fatigue Fibromyalgia Head Trauma Hepatitis A Hepatitis B Hepatitis C Hypertension Hyperglycemia Hypoglycemia Hypothyroidism IBS Infertility Insomnia Lack of Appetite Low Sex Drive Lupus Menopause Migraines Muscle Tension Overweight PMS Seizures Sexual Problems Shortness of Breath Sleep Disturbances Thirst Tremors Ulcers Other Please list any other additional diagnosed disabilities and/or disorders:Do any of your mental health symptoms seem to be related to adjusting to your disability socially or psychologically? Yes No What medications have you used for Mental Health in the past and/or present? Abilify Ativan Adderall BuSpar Celexa Cymbalta Concerta Depakote Effexor Elavil Fanapt Geodon Haldol Invega Invega Sustenna Klonopin Lexapro Lithium Lamictal Latuda Librium Mellaril Prozac Paxil Pristiq Prolixin Risperdal Risperdal Consta Remeron Ritalin Seroquel Saphris Stelazine Strattera Tegretol Trileptal Tofranil Thorazine Valium Vyvanse Wellbutrin Xanax Zoloft Zyprexa Other What's the name of the medication(s)?Which of the above medication(s) have been the most effective and least effective in your treatment? Answer if you’ve received treatment with mental health medication(s):Do you have any allergies, side effects, and/or adverse reactions to any of the above medications? Yes No Please explain:Are you using any alternative health approaches? (ex. massage, acupuncture, homeopathy) Yes No What approaches are you using?Are you using supplements/over-the-counter medications presently? Yes No What are you using and what for?Are you pregnant or have symptoms indicative of pregnancy? Yes No Current Smoking StatusNever SmokedFormer SmokerSmoke EverydaySmoke SometimesDo you have a pharmacy preference? Yes No Pharmacy of Choice Do you have a Primary Care Physician/Doctor? Yes No Do we have your permission to contact your Primary Care Physician? Most insurances require that we ask permission to coordinate care with your doctor. Yes No Doctor's Name Last Office PhoneAddress Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code What information do you want to give us permission to release? Entire Mental Health Record Treatment Plan & Recommendations Diagnosis / Assessments Progress Notes Select AllI want the information selected above to be released in the following form: Electronic Verbal Written Mail Select All I understand this authorization will expire (not to exceed one year or one year from termination of treatment), I further understand that I may revoke this authorization at any time by notifying Renewal Christian Counseling Center in writing, but I understand that previously disclosed information would not be subject to my revocation request.BY CHECKING THIS BOX AND SIGNING THIS FORM, I AM STATING THAT THE INFORMATION PROVIDED IS TRUE. By checking this box and signing this form, I am stating that the information provided is true.First Name First Last Name Last Signature Reset signature Signature locked. Reset to sign again EmailThis field is for validation purposes and should be left unchanged. Copyright 2020 © Renewal Christian Counseling Center
