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Client Medical Information
Fill out and submit the below digital form or
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Client Medical Information – Self Assessment
Location
Liberty
Cornersburg
Case Number
Name
Date of Birth
MM slash DD slash YYYY
Age
Gender
Male
Female
Allergies
Are you currently in counseling elsewhere?
No
Yes
If yes, where?
Current Symptoms
(inc disabilities, disorders, medical/mental concerns)
Current Heath Needs
Current Mediations
(effectiveness, side effects, allergic/adverse reactions)
Exercise
Do you exercise?
Type of Activity & Frequency
Diet
Are you following a specific diet?
Describe
Relevant Medical History
Please list any past health problems, accidents, surgeries (include dates)
Medications taken in the past
(effectiveness, side effects, allergic/adverse reactions)
Immunization Record
Pregnancies/Deliveries
Personal Care Physician
Physician Phone
Physician Address
Date of Last Physician Visit
MM slash DD slash YYYY
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
MM slash DD slash YYYY
Signature
