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| Please do your
best to complete this health history prior to your
appointment. |
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1. PatientName
Last:
First |
| 2.
Patient age (years)
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3. What
are your concerns (behavioral, emotional, sensory,
etc) |
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| 4. How
long have you had these concerns? |
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| Are
there any concerns about sleep not already discussed
above? |
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| Are
there any concerns about suicidality or self-injury
(cutting) not already discussed above? |
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| Are
there any concerns about risky or dangerous
behaviors not already discussed above? |
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| Are
there any concerns about eating/diet/nutrition not
already discussed above? |
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| Are
there any relationship issues or concerns about
sexual development/identity or other sexual issues
not already discussed above? |
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| 5. If
you have previously seen a psychiatrist, who?
was it helpful? what happened? |
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| 6. If
you are seeing or have previously seen a
therapist, who? was/is it helpful? why/why not? |
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| If there
have been psychiatric hospitalizations where? when,?
why? |
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Medications and other treatments |
| What
medications are currently being taken by the
patient? dose? helpful? side effects? |
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| IHave
any medications been tried in the past? what dose?
were they helpful? any side effects? |
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| Are/have
there been any other treatments or services? if yes,
please describe:
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Medical History: |
| Who is the primary
physician?
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physician's phone:
physician's fax: |
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physician's street: |
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| citystate
zip
physician's email: |
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| Are
there any medication allergies? What medications?
What happens? |
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| Is there
any history of medical problems--hospitalizations,
major surgeries, head injury, seizures, chronic
illnesses? |
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| Are
there any other health care providers currently
treating the patient? if yes, who? for what? where? |
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Family History |
| Do any
family members have any mental health
history--depression, anxiety, anger problems, school
problems, tics, psychiatric hospitalizations,
suicides or suicide attempts, legal or substance
abuse history, etc? if yes, what is their
relationship to the patient, and what was their
problem? |
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Social History |
| Who
lives with the patient? |
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| Are
there other friends or family members that the
patient sees often or that the patient is close to? |
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| What
is/are the family's source(s)of income? |
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| Does the
patient attend any daycare or after school programs? |
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| Does the
patient have any history of trauma, abuse,
neglect, or witnessing violence? |
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| Does the
patient have any special interests or hobbies? are
they involved in any extracurricular activities? Is
the patient getting an appropriate amount of
exercise? |
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| Are
there any other family issues that affect the
patient? |
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School history: |
| Does
that patient have any trouble with learning/grades?
Is an IEP in place?
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| Does
that patient have any trouble with
classmates/teasing/bullying? |
| Does
that patient have any trouble with behaviors at
school? |
| Does
that patient have any special skills at school? |
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Legal History |
| Does the
patient have any history of legal troubles, being on
supervision, being arrested? (please elaborate) |
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Substance Abuse History |
| Does
that patient have any substance abuse history?
(please describe) |
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| Thank
you for your thoughtful input. Now, just submit your
answers! |
