Mental Health Paperwork

(Feel free to use this as a guideline for your patients to keep track of any acquired IC information, and post them in the 'Approved Applications' area of the Information forums under the patient's application thread.)


Personal Information
Name:
DOB:
Sex:

Complaint
What is your major complaint?
Have you previously suffered from this?
Previous treatment:

Current Symptoms


Medical History
Exercise frequently:
Allergies:
What medications are you currently using?
Previous Diagnoses/Mental Health treatment:
Previous medications:
Previous Medical Conditions:
Previous surgeries:

Family History
Were you adopted? What age?
How is your relationship with your family?
Siblings?
Are your parents married? Divorced? Remarried?
Family medical/mental conditions:
Treated with medication?
Have any immediate family members died? Committed suicide?
Describe any neglect, trauma, and abuse if you've suffered:

Development
Highest level of education:
Have you served in the military?

Present Situation
Work?
Are you Married? Divorced? Prior Marriages?
What is your sexual orientation?
Are you sexually active?
How is your relationship with your partner?
Do you have children?
Relationship with children?
Are you religious?
Have you ever been arrested? Why?
Have you done any drugs? Frequency?
Have you been treated for abuse?

Anything else: