Client Medical Information – Churchill Counseling

Client Medical Information – Self Assessment

Location*

Case Number

Name*

Date of Birth*

Age*

Gender*

Are you currently in counseling elsewhere?*

No
Yes

If yes, where?

Allergies

Current Symptoms*

(inc disabilities, disorders, medical/mental concerns)

Current Mediations

(effectiveness, side effects, allergic/adverse reactions)

Relevant Medical History

Please list any past health problems, accidents, surgeries (include dates)

Medications taken in the past

(effectiveness, side effects, allergic/adverse reactions)

Current Heath Needs

Exercise

Do you exercise?

Type of Activity & Frequency

Diet

Are you following a specific diet?

Describe

Immunization Record

Pregnancies/Deliveries

Personal Care Physician*

Physician Phone*

Physician Address*

Date of Last Physician Visit

Refereal

Client referred to PCP by CCS staff

May we share treatment info with your PCP?*

Yes
No

Has client or any relative ever attempted suicide? If so who?*

Has client or any blood relative ever had a mental disorder? If so who?*

Do you have Advanced Directive for Mental Health?*

Information will be given to you upon your request.

Yes
No

Is there a need for assistive technology in the provision of services?*

Yes
No

If so, what?

Signature

Client/Guardian Name*

Relationship to Client*

Date*

Signature*