Medical Intake Form - Graceway Counseling Center

General Medical History

What brings you to the office?

Have you ever been diagnosed with a mental health diagnosis?

Yes
No

Please list mental health diagnosis:

e.g., Depression, Anxiety, PTSD, Bipolar Disorder, Schizoaffective D/o, Schizophrenia, ADHD

Have you ever been seen by a psychiatrist, psychologist, therapist/counselor, or other mental health provider?

Yes
No

Who/Where were you seen / Dates Seen / For What Problem / Type of Treatment

provider seen, dates seen, for what problem, type of treatment

Have you ever been hospitalized for psychiatric care?

Yes
No

Dates hospitalized, Where and for what, type of treatment

Please list all medications you are currently taking, including over-the-counter medications, herbals, and supplements:

medication, dosage, # times per day, for what condition, who prescribes it

List any other psychiatric medication you have taken in the past. Please describe why you no longer take this medication (i.e. intolerance, side effect, not therapeutic, etc.):

Do you have a primary care physician?

Yes
No

What is your physician's name and when did you last see them?

What medical illnesses have you been diagnosed with?

If you have never been diagnosed with any medical illnesses, please enter "none"

Have you ever had any surgeries?

Yes
No

Please describe:

Please list any food or environmental allergies:

If you have no known allergies, please enter "None"

Please list any medication allergies:

If you have no known allergies, please enter "None"

Substance Use History

Do you have any history with using any of the following substances:

Tobacco
Alcohol
Marijuana, D8, K2, "spice"
Cocaine
Opiates (Heroin, Morphine, Percocet, Norco, Oxycodone, Tyllenol #3, Dilaudid, Fentanyl)
Tranquilizers/sedatives (Xanax, Ativan, Klonopin, Valium, Ambien, Lunesta, Belsomra)
PCP, LSD, Mushrooms, Etc
Methamphetamine
No History of any of these substances

Please describe: Last time used, how often, how much do you use in one sitting

Last time used, how often, how much do you use in one sitting

Please list any significant family history:

heart disease, cancer, Bipolar, Schizophrenia, Depression, Anxiety, etc

Anything else our provider should know?

Insurance Information

General Medical History

Substance Use History