Full Legal Name
Please fill this session if someone other than the patient is responsible for the payment of services
Directions to the patient: The Following information about your health is very important for us to provide you with the best possible care in a safe way. Incorrect information may be dangerous to your health. All questions must be answered completely and accurately. The health history questionnaire will become a part of the patient’s mental health record and will be considered confidential information.
Using any type of drug (including but not limited to alcohol)?
Thoughts of harming yourself?
Thoughts of harming someone else?
Fear of going out in public?
Experiencing parental stress?
Feel as if someone is out to get you?
Feeling of helplessness?
Experiencing unusual amounts of headaches
Having relationship problems?
Experiencing stress on the job?
Others, please list:
What are other problems with your health that you know of?