Client History Form

Your Name

Your Phone

Your Email

Your Date of Birth

HEALTH & MEDICAL TREATMENT HISTORY

Are you discharging from medical detox and/or an inpatient facility?
YesNo

If yes, please include the date of admission, discharge date, name of program, the reason for and duration of stay.

Were you previously assessed for substance use at another outpatient facility?
YesNo

If yes, please include date, location, and reason for assessment.

Was the treatment and/or assessment related to a legal charge or court order?
YesNo

If yes, please include the type of charge, conviction status, and state in which the charge occurred.

Within the last 12 months, have you been treated or diagnosed with any of the following (select all that apply and explain):

SeizuresDiabetesHigh Blood PressureHeart DiseaseBipolarDepressionBowel ProblemsSchizophreniaUlcersHepatitisCirrhosisChest PainCancerShortness of Breath Infectious DiseasesLiver ProblemsKidney ProblemsLung ProblemsAbscessSerious Infections PancreatitisHead InjurySurgeryBroken BonesTBHIVSTD'sPsychiatric Hospitalization Suicide AttemptsAddictionsEating DisordersVisual Impairments Hearing Impairments Speech ImpairmentsThreatened/Harmed OthersOther (please explain)None

Comments

Do you have any allergies?
YesNo

If yes, what type and is an EpiPen needed?

Do you have any disabilities
NoneHearingVisualAmbulatoryOther (please explain)

Comments

Have you been tested for HIV?
YesNo

If yes, when, and were results positive or negative?

Have you been tested for TB?
YesNo

If yes, when, and were results positive or negative?

Have you been tested for Hepatitis?
YesNo

If yes, when, and were results positive or negative?

Please list any over the counter and/or prescribed medications that you may be taking or prescribed and not taking (please include medication name, dosage, instructions & reason for and duration of a prescription)

Do you have any concerns about your medications?
YesNo

If yes, please explain

Are you required to be on a special diet by your doctor?
YesNo

If yes, please explain

Are you pregnant?
YesNo

Comments

Date of last physical exam

Outcomes of physical exam

Total admissions to the hospital and reason for admission

[cf7mls_step cf7mls_step-1 “Next” “”]SOCIAL & ENVIRONMENTAL HISTORY

How old are you?

Describe your relationship status

Describe your gender identity & sexual orientation

How many children do you have (include age, gender, and custody status)?

Where do you reside and with whom?

Please describe the use of and/or access to alcohol and drugs in the home

How has substance use affected your family, peer, and social relationships?

What is your current education status (include a description of the program if currently enrolled in school)?

What is your current employment status (include the place of employment, position, length of employment and/or unemployment, and reason for unemployment, if applicable)?

How has substance use affected your education or employment?
[cf7mls_step cf7mls_step-2 “Back” “Next” “Step 2”]MENTAL HEALTH HISTORY

Have you experienced any of the following traumatic events (select all that apply)?

BullyingEmotional AbuseNon-Partner Physical AbuseSexual Assault or AbuseViolenceNeglectOtherNone

If yes, including when it occurred and a description of the services received, as a result:

Have you ever been diagnosed with depression, bipolar disorder, anxiety, or other mood disorder?
YesNo

If yes, include severity and duration

Have you ever experienced hallucinations and/or been diagnosed with schizophrenia or other psychotic disorder?
YesNo

If yes, include the age of onset, involvement of substance use, and type of hallucination

Are you having, or have you ever had thoughts, of harming yourself or anyone else?
YesNo

If yes, include thoughts or attempts at suicide or homicide, and the number of hospitalizations due to suicidal or homicidal ideation

Are you currently seeing a therapist and/or psychiatrist?
YesNo

If yes, include name, the reason for services, frequency of visits, and last visit

Have you previously received mental health treatment?
YesNo

If yes, include reason, types of services, location, and date of services
[cf7mls_step cf7mls_step-3 “Back” “Next” “Step 3”]SUBSTANCE USE HISTORY

Do you have a family history of substance use issues (select all that apply)?
Yes, Immediate RelativesYes, Extended RelativesNo Biological History KnownNone

Comments

Have you ever felt you should stop, or tried to stop, cut down, or control your substance use?
YesNo

If yes, explain when & why.

What is your longest period of voluntary abstinence from the mind or mood-altering substances & why.

Have you ever been admitted to a hospital for medical detoxification from a substance?
YesNo

If yes, include how many times, when and where.

Are you currently, or have you ever attended a mutual-help support group such as AA, NA, or another support group?
YesNo

If yes, include which type and how often you attended

Have you ever felt annoyed by people criticizing your alcohol or drug use?
YesNo

If yes, please explain

Have you ever felt guilty about your use of alcohol or drugs?
YesNo

Please explain

Over time, have you needed to increase your consumption of alcohol or drugs to get the same effects?
YesNo

If yes, specify which substance(s)

Have you ever used alcohol or drugs to alleviate a hangover?
YesNo

If yes, include how often, what substance(s), and last occurrence.
[cf7mls_step cf7mls_step-4 “Back” “Next” “Step 4”]SUBSTANCE USE HISTORY

When was your last use of drugs or alcohol (include all substances)

In the days following your last date of substance use have you experienced any of the following (select all that apply)?
NauseaInsomniaIrritabilityAnxietyShakinessDecreased AppetiteAgitationCravingOther (please explain)None

If yes, specify for what substance(s)

What negative consequences have you experienced as a result of your substance use?

Please indicate any substances that you have experimented with or used on a regular basis.

Alcohol
YesNo

If yes, specify the age of first use, average amount, frequency of use, date of last use & last used amount.

Benzodiazepine, Tranquilizers, Barbituates
YesNo

If yes, specify the age of first use, average amount, frequency of use, date of last use & last used amount

Cannabis
YesNo

If yes, specify the age of first use, average amount, frequency of use, date of last use & last used amount

Cocaine, Crack Cocaine
YesNo

If yes, specify the age of first use, average amount, frequency of use, date of last use & last used amount

Hallucinogens, LSD, Mushrooms, Ecstasy, PCP
YesNo

If yes, specify the age of first use, average amount, frequency of use, date of last use & last used amount

Heroin, Opium, Methadone, Presciption Pain Pills
YesNo

If yes, specify the age of first use, average amount, frequency of use, date of last use & last used amount

Inhalants, Nitrous, Freon, Duster, Paint Thinner, Whip-Its
YesNo

If yes, specify the age of first use, average amount, frequency of use, date of last use & last used amount

Methamphetamine, Amphetamine
YesNo

If yes, specify the age of first use, average amount, frequency of use, date of last use & last used amount

Cigarettes, Cigars, Dip, E-cigarettes
YesNo

If yes, specify the age of first use, average amount, frequency of use, date of last use & last used amount

Synthetic or Other Drugs, Spice, K2, Bath Salts
YesNo

If yes, specify the age of first use, average amount, frequency of use, date of last use & last used amount

Caffeine (Pills or Powder)
YesNo

If yes, specify the age of first use, average amount, frequency of use, date of last use & last used amount

Over the Counter Drugs, Cough Syrup, Tripple C’s
YesNo

If yes, specify the age of first use, average amount, frequency of use, date of last use & last used amount

[cf7mls_step cf7mls_step-5 “Back” “Step 5”]