Client Medical Information

Fill out and submit the below digital form or click here for the printable form.

Client Medical Information - Self Assessment
Location
Case Number
Name
Date of Birth
Date Format: MM slash DD slash YYYY
Age
Gender
Allergies
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
Date Format: 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
Date Format: MM slash DD slash YYYY
Signature

Client Medical Information - Self Assessment