Medical History "*" indicates required fields Step 1 of 5 20% Which best describes you?*ChooseNew ClientPrevious ClientParent or Guardian of the ClientOffice Location*Choose OneBay CityGrosse PointeMidlandMount ClemensPort HuronSaginawFirst Name* First Last Name* Last Date of Birth* Month Day Year Age*Height* Weight* Race*Choose OneAmerican Indian or Alaska NativeAsian American or AsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteTwo or More RacesEthnicity*Choose OneHispanic or LatinoNot Hispanic or LatinoPharmacy of Choice (if any) Would you like us to provide you with Advance Directives training and planning in case of a mental health emergency?*Choose OneYesNoHave you ever seen a Psychiatrist before?*Choose OneYesNoIf yes, whom?* Are you in any pain?*Choose OneYesNoIf yes, rate your pain level from 1-10 (1 being the least and 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 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 Thirst Tremors Ulcers Other If other, what are the conditions?* 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?*Choose OneYesNoAre you pregnant or have symptoms indicative of pregnancy?*Choose OneYesNoCurrent smoking status?*Choose OneNever SmokedFormer SmokerSmoke EverydaySmoke Sometimes 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 If other, what are the medications?* 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?Choose OneYesNoIf yes, please specify?* Are you using supplements/over-the-counter medications presently?*Choose OneYesNoIf yes, please explain?* Are you using any alternative health approaches? (ex. massage, acupuncture, homeopathy)*Choose OneYesNoIf yes, list any.* Do you have a Primary Care Physician?*Choose OneYesNoDo we have your permission to contact your Primary Care Physician? Most insurances require that we ask permission to coordinate with your doctor, usually by letter.*Choose OneYes, I give Renewal permission to contact my Primary Care Physician.No, I do not give Renewal permission to contact my Primary Care Physician. No further documentation is needed.Doctor's Name:* Last Office Number*Address* Street 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 Disclosure InformationWhat 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 Other Select All * I understand that if the person(s) or organization(s) that receives the information is not a health care provider or health care plan covered by federal privacy regulations, the information described above may be redisclosed and no longer protected by these regulations.* 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.Relationship to Client*Self - I am the ClientParent / Legal GuardianDate* MM slash DD slash YYYY First Name* First Last Name* Last Client or Parent/Guardian Signature:* Reset signature Signature locked. 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