Medical History

Name:

DOB:

Primary Care Physician:
List all doctors or medical specialists you see now or have seen in the past year:

Date of last physical exam

Examiners name

Describe any current medical problems or recent changes in your physical condition:

Height?	How is your appetite?	good	fair	poor
Weight?	How well do you sleep?	good	fair	poor
Are you gaining weight? (amount)	How is your energy level?	good	fair	poor
Are you losing weight? (amount)	Rate your general health	good	fair	poor
Date gain/loss began?

List any hospitalizations:

List all medications you are taking. Include non-prescription drugs and health supplements.

Do you have any allergies to medication?

Please Specify:

Check or type X for any of the following which you use or have used:

Further comments on alcohol or drug use:

Has client had any previous mental health treatment or counseling?

If yes, please list Date, Location of Therapist,reason for seeing therapist and any comments

Check any of the following symptoms you have had in the past three months:

Check any of the following conditions you have had.

Have any of your blood relatives had any of the following conditions? Indicate who.

X condition	Who?	X condition	Who?
Alcohol/drug abuse		Nervous breakdown
Anxiety or Panic Disorder		Obsessive/Compulsive Disorder
Attention Deficit Disorder		Psychiatric Hospitalization
Bipolar Illness		Schizophrenia
Depression		Seizure Disorder
Dementia		Suicide

Additional comments on your health or family's health history: