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Divine Counseling and Wellness, INC

131 Wickham Ave, Middletown, NY, 10940

Biographic information

First/Last Name

Phone Number

Health insurance

Emergency Contact Name

Occupation

Group

Emergency Contact Number

Address

Last 4 of Social Security Number

Policy Number

Emergency Contact address

Date of Birth

Who referred you to DC&W

Name of Policyholder

What is the main concern that led you to consult DC&W

Medical History

Are you allergic to any medications?

Yes

Are you allergic to any other substances?

Yes

What is the date of your most recent physical examination?

What is the name of your physician?

Have you ever donated blood?

Yes

Have you had any medical illnesses in the past?

Yes

What is your physician’s address?

What is your physician’s telephone number?

Do you authorize me to communicate with your physician?

Yes

Have you had any surgical operations or injuries?

Yes

What is your physician’s address?

Have you ever had a seizure?

Yes

Have you ever had a head injury?

Yes

If you answered yes to question 3, did you lose consciousness?

Have you ever been hospitalized for a psychiatric disorder? If yes, when?

What is the name of your former therapist?

Have you ever had out of hospital treatment for a psychiatric disorder? If yes, what was the disorder, where and when did you receive treatment?

What is your former therapist’s address?

If you had a head injury, When did it happen ?

If you had a head injury, When did it occur ?

Have you ever been hospitalized for a psychiatric disorder? If yes, when?

What is your former therapist’s telephone number?

Do you authorize me to communicate with him/her?

Yes

Which medications are you currently taking (medical or psychiatric)? Please list the drug, dosage, frequency, and prescribing physician.

Do you use non-prescription medications? If yes, which ones?

Yes

Do you currently use or have you ever used recreational or illegal drugs? If yes, which drugs and how often?

Yes

Do you drink alcohol?

Yes

Have you ever tried to cut down on how much you drink?

Yes

Have you felt guilty about anything resulting from your drinking

Yes

Do you feel better if you have a drink early in the day?

Yes

Do you smoke? If yes, what do you smoke and how often?

Do you use nonsmoking forms of tobacco? If yes, which?

How many cups of coffee and/or tea do you drink per day?

How many cans of soda do you drink per day?

Family Psychiatric History

Has anyone in your family ever had a psychiatric disorder? (I.e. depression, mania, schizophrenia, drug or alcohol abuse, obsessive-compulsive disorder, panic disorder, phobias, suicide, etc.) Please indicate diagnosis below if know.

Mother

Maternal Grandparents

Father

Brother

Sister

Paternal Grandparents

Aunts/Uncles/Cousins

Relationship History

What is your marital status?

If married, what was your wedding date?

If married, what is your spouse’s date of birth? _

If married, what is your spouse’s/partner’s occupation?

If widowed, what was the date of your spouse’s/partner's death?

If widowed, what was the cause of your spouse’s/partner’s death?

If separate and/or divorced, what was your date of separation/divorce?

If separate and/or divorced, what is the reason?

Please list all of your children’s names and dates of birth below.

Do you engage in safe sex?

Yes

Do you have any sexual concerns?

Yes

Which form(s) of birth control do you use?

Please list all individuals currently living in your household and their relationship to you.

Family Medical History

Your mothers's name and age

If your mother is deceased, what was date and cause of death.

Your Father's name and age

If your Father is deceased, what was date and cause of death.

Has your Mother had any serious illnesses? if yes, please list below

Has your Father had any serious illnesses? if yes, please list below

Please list all of your bothers and sisters and any serious illnesses below. Use the list to the right for reference.

Decreased vision/ eye path
Dizziness/Vertigo
Decrease in hearing
Chest
Decrease in energy
Difficulties with organization
Cough/ Asthma
Menstrual/ reproductive problems/infection
Decrease in appetite
Nausea/ vomiting/ diarrhea
Bloody or black stool
Frequent or Severe headaches
Self-induced vomiting with or without ipecac
Anxiety/panic attacks
Sleep difficulty
Racing Thoughts
Wear eyeglasses/ contacts
Earaches/ buzzing or other sounds
Difficulty Swallowing
Shortness of Breath
Difficulty concentrating/distractibility
Impulsivity
Abdominal pains
Eating problems
Using laxatives/diuretics or diet pills for weight loss
Weight Loss/Weight Gain
Blood in Urine
Convulsions/ Seizures
Depression
Avoidance of public places
Decrease in motivation
Suicidal thoughts/ fears

Does your primary care physician know about the symptoms you have listed

Yes

Have you ever been exposed to abuse?

Yes

Was the abuse physical,sexual and/or emotinal

Who was involved in the abuse?

Are you distressed about any part of your appearance?

Yes

EDUCATIONAL HISTORY

Please list your educational history, school location and dates attended

OCCUPATIONAL HISTORY

Please list your occupatinal history and dates worked.

Were you exposed to any dangeous sunstances while at any of these jobs?

Have you performed any military service?

Yes

Have you been released on honorable discharge?

Yes

Have you served during the war time?

Yes

Have you had any problems with the law? If yes, please explain below.

DEVELOPMENTAL/ADAPTIVE HISTORY

To the best of your knowledge, was your mother exposed to stresses, drugs, or dangerous substances while she was pregnant with you? If yes, what were they?

Were there any difficulties with your birth? If yes, what were they?

Have you had any recent stresses and/or relevant stresses in the past? If yes, please list them.

Which stresses have you overcome in the past?

How did you overcome the stresses?

What was the best period of your life?

What are your personal strengths?

What are your weaknesses?

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Today's Date

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