QC Counselor PLC - Adult Health History Form
Submit
I wish to see:
*
Rick Martenson MS Ed., LMHC
Mollie A. Schmelzer MS Ed., LMHC
Sandra Risch LCSW
Patient Name:
First Name
Last Name
Date:
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Year
Family Physician:
Referred By:
Date of Birth:
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22
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Day
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2020
2019
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2016
2015
2014
2013
2012
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2010
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2008
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2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
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1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Gender:
Male
Female
Marital Status:
Single
Married
Divorced
Number of Marriages:
Years Currently Married:
Spouse's Name:
First Name
Last Name
Child's Name:
First Name
Last Name
Age:
Living WIth You
Yes
No
Shared Custody
Child's Name:
First Name
Last Name
Age:
Living WIth You
Yes
No
Shared Custody
Child's Name:
First Name
Last Name
Age:
Living WIth You
Yes
No
Shared Custody
Child's Name:
First Name
Last Name
Age:
Living WIth You
Yes
No
Shared Custody
Current Employer:
Position:
Yrs Employed:
Previous Employer:
Position:
Yrs Employed:
Previous Employer:
Position:
Yrs Employed:
Military Service:
Yes
No
Branch:
Rank:
Presenting Problem:
How Long?
Stressors?
Symptom checklist:
Sleeping problems
Nightmares
Feeling depressed most of the day
Crying spells
Feeling irritable and restless
Loss or gain of weight
Change in energy level
Racing thoughts
Forgetfulness
Dislike of one's body
Lack of confidence
Moodiness
Loss of motivation
Diminished pleasure
Feelings of hopelessness
Feelings of guilt
Feelings of worthlessness
Diminished ability to think
Diminished ability to concentrate
Indicision
Suicidal thoughts
Suicidal plans
Symptom checklist:
Previous suicidal actions
Hearing voices outside your head
Hearing voices inside your head
Doing repetitive things
Needing things to be "just so"
Hearing a voice calling your name
Hearing a voice telling you you're bad
Hearing a voice urging you to harm yourself
Seeing things others do not see
Experiencing strange tastes or smells
Frightening thoughts
Having unusual beliefs
Ideas that seem odd to others
Thinking the Tv is talking to you
Thinking someone is out to harm you
Believing you have special powers
Believing you are cursed
Unexplainable sensory experiences
Feeling suspicious of others
Preference of being alone
Not enjoying close relationships
Beliefs that seem odd or unusual
Have you ever felt so good or hyper that others thought you were not your normal self?
Yes
No
Have you ever been so mad that you shouted at people or started arguments or fights?
Yes
No
Have you ever felt much more self-confident than usual?
Yes
No
Have you ever gotten much less sleep and found you didn't miss it?
Yes
No
Have you ever been much more talkative or spoke much faster than usual?
Yes
No
Have thoughts raced in your head or you couldn't slow your mind down?
Yes
No
Have you been so easily distracted that you had trouble staying on track or concentrating?
Yes
No
Have you ever had much more energy than usual?
Yes
No
Have you ever been much more active or did many more things than usual?
Yes
No
Have you ever been much more outgoing or social than usual?
Yes
No
Have you ever been much more interested in sex than usual?
Yes
No
Have you ever done things that were unusual or others thought excessive, foolish or risky?
Yes
No
Has spending money ever gotten you or your family into trouble?
Yes
No
Have any of your blood relatives had bipolar disorder (Manic Depression)?
Yes
No
Has a mental health professional ever told you that you had bipolar disorder?
Yes
No
Symptoms of presenting problem:
You're scared to death as if losing your mind
You have shortness of breath
You feel a smothering sensation
You have accelerated heart rate
You feel trembling or shaking
You've been sweating or choking
You feel nausea or abdominal distress
You feel like you, or the world is not real
You feel numbness or tingling
You feel hot flashes or chills
You have chest discomfort
You've had an out-of-body experience
You have a fear of dying
You have a fear of going crazy
You have excessive worrying
You have dizziness
You are a perfectionist
You fear doing something uncontrolled
You fear places where escape is difficult
You fear places when getting help is difficult
You fear being out of your safety zone
You fear one or more situations
You avoid one or more situations
You do repititious acts
You have repititious thoughts
Strange thoughts that intrude on your mind
You have daily muscle tension
You can't remember much from your childhood
Symptoms of presenting problem:
You have a sense of not being yourself
You have an inability to control pain
You have uncontrolled pain
You often lose awareness of time
You have severe and frequent headaches
You hav e trouble telling people how you feel
You have impulses you cannot control
You are worried about your eating
You are worried about your weight loss
You are worried about your weight gain
You make yourself throw up
You go without food for extended time
You use diet pills or laxatives
You are a binge eater
You exercise until you are exhausted
Your body image interferes with your life
You struggle with inattention
You struggle with distractibility
You often fail to finish tasks
You have difficulties with the law
You have mood fluctuations
You do self-damaging acts
You tend to be overly dramatic
You have an inflated sense of self-importance
You tend to be nervous around others
You tend to be overly dependent on others
You need excessive amounts of reassurance
You have an excessive need for attention
Were you sexually abused as a child?
Yes
No
Were you physically abused as a child?
Yes
No
Were you emotionally abused as a child?
Yes
No
Were you sexually abused as a adult?
Yes
No
Were you physically abused as a adult?
Yes
No
Were you emotionally abused as a adult?
Yes
No
Have your experienced a psychologically distressing event?
Yes
No
Do you ever re-experience the distressing event?
Yes
No
Have you had recurrent, intrusive recollections?
Yes
No
Have you had recurrent dreams?
Yes
No
Have you acted or felt as if the event were reoccurring?
Yes
No
Have physicians had difficulty diagnosing or treating your problem?
Yes
No
Have you had more than your share of illnesses or injuries?
Yes
No
Have you ever been physically violent?
Yes
No
Have you ever been arrested?
Yes
No
Are you presently involved in a lawsuit?
Yes
No
Have you ever been involved in a lawsuit?
Yes
No
Have you ever been hospitalized for psychiatric problems?
Yes
No
Have you ever been hospitalized for substance problems?
Yes
No
Have you ever taken medications for psychiatric problems?
Yes
No
Have you had any counseling or psychotherapy?
Yes
No
Present health problems:
Do you use alcohol
Yes
No
Did you ever use alcohol?
Yes
No
Do you presently use caffeine?
Yes
No
Did you ever use caffeine?
Yes
No
Do you presently smoke cigarettes?
Yes
No
Did you ever smoke cigarettes?
Yes
No
Do you presently use OTC drugs?
Yes
No
Did you ever use OTC drugs?
Yes
No
Do you use illegal drugs?
Yes
No
Did you ever use illegal drugs?
Yes
No
Mother's name:
First Name
Last Name
Mother's age:
Deceased?
Yes
Father's name:
First Name
Last Name
Father's age:
Deceased?
Yes
Siblings Name and Age:
Is there a history of substance abuse in your family or origin?
Yes
No
Wishing to see:
*
Rick Martenson MS Ed., LMHC
Mollie A Schmelzer MS Ed., LMHC
Sandra Risch LCSW
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