Client History Form

CLIENT HISTORY

This is a self-reporting form used to gather relevant clinical information. This is not considered an assessment. However, if you need an assessment for any reason (DWI, Legal, Custody, Employment, etc.), please notify staff to accommodate your needs.






    YesNo



    YesNo



    YesNo


    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



    YesNo



    NoneHearingVisualAmbulatoryOther (please explain)



    YesNo



    YesNo



    YesNo




    YesNo



    YesNo



    YesNo






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    BullyingEmotional AbuseNon-Partner Physical AbuseSexual Assault or AbuseViolenceNeglectOtherNone



    YesNo



    YesNo



    YesNo



    YesNo



    YesNo


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    Yes, Immediate RelativesYes, Extended RelativesNo Biological History KnownNone



    YesNo




    YesNo



    YesNo



    YesNo



    YesNo



    YesNo



    YesNo


    [cf7mls_step cf7mls_step-4 “Back” “Next” “Step 4”]SUBSTANCE USE HISTORY



    NauseaInsomniaIrritabilityAnxietyShakinessDecreased AppetiteAgitationCravingOther (please explain)None




    YesNo



    YesNo



    YesNo



    YesNo



    YesNo



    YesNo



    YesNo



    YesNo



    YesNo



    YesNo



    YesNo



    YesNo


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