Medical History: Doña Ana FOR DOÑA ANA COUNTY ONLY. Intake forms are securely encrypted and HIPAA compliant. Medical History: Doña Ana ID # CLIENT FIRST NAME*CLIENT LAST NAME*CLIENT DOB* MM slash DD slash YYYY EMAIL* HOW IS THE CLIENT’S PHYSICAL HEALTH?*SIGNIFICANT OR RELEVANT MEDICAL CONDITIONS?*ANY SERIOUS INJURIES INCLUDING SURGERIES, BRAIN INJURIES, CONCUSSIONS OR HOSPITALIZATIONS?* YES NO UNKNOWN EXPLAIN:DOES THE CLIENT HAVE A PRIMARY CARE PHYSICIAN (PCP)?* YES NO DOES THE CLIENT NEED ASSISTANCE FINDING A PCP?* YES NO PCP’S NAME*PCP'S PHONE*WHEN WAS PCP SEEN LAST?*REASONDOES SWFGC HAVE PERMISSION TO SHARE INFORMATION WITH YOUR PCP?* YES NO ARE ALL IMMUNIZATIONS UP TO DATE?* YES NO UNKNOWN HAS THE CLIENT EVER TAKEN ANY MEDICATIONS (INCLUDING PSYCHOTROPIC MEDICATIONS, VITAMINS, SUPPLEMENTS, OR OVER-THE-COUNTER PRODUCTS?* YES NO UNKNOWN MEDICATIONS*NAME OF MEDICATIONDOSAGEHOW OFTEN?PURPOSECURRENTLY TAKING? DOES THE CLIENT HAVE ANY ALLERGIES (FOOD, ENVIRONMENTAL, MEDICATIONS)?* YES NO UNKNOWN EXPLAINKNOWN FAMILY HEALTH CONDITIONS (I.E. ASTHMA, DIABETES)?*IS THE CLIENT UNDER 18?* YES NO DEVELOPMENTAL HISTORYWAS THE PREGNANCY WITH THIS CLIENT PLANNED?* YES NO UNKNOWN WAS THE PREGNANCY FULL TERM?* YES NO UNKNOWN IF NO, HOW MANY MONTHS/WEEKS?ANY PROBLEMS DURING PREGNANCY (INCLUDING DOMESTIC VIOLENCE, SUBSTANCE ABUSE)?* YES NO UNKNOWN EXPLAIN:WERE THERE ANY COMPLICATIONS DURING DELIVERY?* YES NO UNKNOWN EXPLAIN:WERE MOTHER/CLIENT SEPARATED IMMEDIATELY AFTER BIRTH?* YES NO UNKNOWN EXPLAIN:OTHER PARENT/CLIENT SEPARATIONS AFTER BIRTH?* YES NO UNKNOWN EXPLAIN:DESCRIBE CLIENT AS AN INFANT/TODDLER (I.E. CHEERFUL, FUSSY, CUDDLY):*DEVELOPMENTAL MILESTONESAGE CLIENT FIRST SAT UP* EARLY ON-TIME LATE UNKNOWN TOOK 1ST STEPS* EARLY ON-TIME LATE UNKNOWN SPOKE FIRST WORD* EARLY ON-TIME LATE UNKNOWN FED THEMSELVES* EARLY ON-TIME LATE UNKNOWN TOILET TRAINED DURING DAY* EARLY ON-TIME LATE UNKNOWN TOILET TRAINED AT NIGHT* EARLY ON-TIME LATE UNKNOWN ANY CURRENT OR PAST HISTORY OF DEVELOPMENT CONCERNS?* YES NO UNKNOWN DESCRIBE:PSYCHIATRIC HISTORYHAS CLIENT EVER HAD THERAPY BEFORE?* YES NO UNKNOWN PAST DIAGNOSIS, IF KNOWN:IS CLIENT CURRENTLY RECEIVING SERVICES FROM ANOTHER BEHAVIORAL HEALTH PROVIDER?* YES NO CONTACT INFORMATION:*DO YOU PLAN TO DISCONTINUE SERVICES WITH CURRENT PROVIDER?* YES NO UNKNOWN LIST PAST THERAPY SERVICES:*DATESPROVIDERREASON WHY IS THE CLIENT UNDER THE CARE OF A PSYCHIATRIST?* YES NO PSYCHIATRIST NAME*MAY SWFGC TALK TO THE PSYCHIATRIST? (If yes, please sign a release of infomation.)* YES NO HAS THE CLIENT EVER HAD A HISTORY OF SUICIDAL OR HOMICIDAL TENDENCIES?* YES NO UNKNOWN EXPLAIN:HAS CLIENT EVER BEEN IN HOSPITALIZED FOR BEHAVIORAL HEALTH ISSUES?* YES NO UNKNOWN WHEN AND WHERE:DID YOU FEEL CLIENT’S TREATMENT WAS HELPFUL?* YES NO EXPLAINIS THERE A HISTORY OF MENTAL ILLNESS IN THE FAMILY (I.E. ANXIETY, DEPRESSION, ADHD)?* YES NO UNKNOWN WHOM AND WHAT?I HAVE FILLED OUT THIS INFORMATION AS ACCURATELY AS I CAN FOR THE ABOVE NAMED CLIENT.NAME*RELATION TO CLIENT*DATE* MM slash DD slash YYYY
