QC Counselor PLC - Youth Health History Form

Patient Name:

First NameLast Name

Date:

MonthDayYear

Family Physician:

Referred By:

Gender:

Date of Birth:

MonthDayYear

Father's name, address:

Father's Phone:

Area CodePhone Number

Custodial Parent:

Mother's name, address:

Mother's Phone:

Area CodePhone Number

Custodial Parent:

Presenting Problem:

How Long?

Stressors?

Symptom checklist:

Symptoms of presenting problem:

Were you sexually abused as a child?

Were you physically abused as a child?

Were you emotionally abused as a child?

Do you ever re-experience the distressing event?

Have you had recurrent, intrusive recollections?

Have you had recurrent dreams?

Have you acted or felt as if the event were reoccurring?

Have physicians had difficulty diagnosing or treating your problem?

Have you had more than your share of illnesses or injuries?

Have you ever been physically violent?

Have you ever been arrested?

Have you ever been hospitalized for psychiatric problems?

Have you ever been hospitalized for substance problems?

Have you ever taken medications for psychiatric probelms?

Have you had any counseling or psychotherapy?

Present health problems:

Do you use alcohol

Did you ever use alcohol?

Do you presently use caffeine?

Did you ever use caffeine?

Do you presently smoke cigarettes?

Did you ever smoke cigarettes?

Do you presently use OTC drugs?

Did you ever use OTC drugs?

Do you use illegal drugs?

Did you ever use illegal drugs?