Medical History: Santa Fe & Rio Arriba

FOR SANTA FE AND RIO ARRIBA COUNTIES ONLY. Intake forms are securely encrypted and HIPAA compliant.

Medical History: Santa Fe, Rio Arriba

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
- UNKNOWN
DOES THE CLIENT NEED ASSISTANCE FINDING A PCP?*
- YES
- NO
PCP’S NAME*
PCP'S PHONE*
WHEN WAS PCP SEEN LAST?*
REASON*
DOES 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 MEDICATION DOSAGE HOW OFTEN? PURPOSE CURRENTLY TAKING?
DOES THE CLIENT HAVE ANY ALLERGIES (FOOD, ENVIRONMENTAL, MEDICATIONS)?*
- YES
- NO
EXPLAIN
KNOWN FAMILY HEALTH CONDITIONS (I.E. ASTHMA, DIABETES)?*
IS THE CLIENT UNDER 18?*
- YES
- NO
DEVELOPMENTAL HISTORY
WAS 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 MILESTONES
AGE CLIENT FIRST SAT UP*
- EARLY
- ON-TIME
- LATE
- UNKNOWN
TOOK 1ST STEPS*
- EARLY
- ON-TIME
- LATE
- UNKNOWN
SPOKE 1ST 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 HISTORY
HAS 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:*
DATES PROVIDER REASON 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
- UNKNOWN
EXPLAIN
IS 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

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Medical History: Santa Fe & Rio Arriba

DEVELOPMENTAL HISTORY

DEVELOPMENTAL MILESTONES

PSYCHIATRIC HISTORY

NAME OF MEDICATION	DOSAGE	HOW OFTEN?	PURPOSE	CURRENTLY TAKING?

DATES	PROVIDER	REASON WHY