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Medical/SA history

Prelude Behavioral Services
3451 Easton Blvd.
Phone 515-262-0349
Fax 515-266-6808
 Client Information
  First Name:  * Last Name:  *  
           
  Date of Birth:  * Gender:  *  
         
  Address: City:  
  State: Zip Code :  
  Phone No:  
Health Problems
  Column 1 Comments
Do you have vision problems?
Do you have hearing difficulties?
Do you have sinus problems or chronic infections?
Do you have dental problems?
Do you have asthma?
Do you have lung disease?
Do you have heart disease?
Do you have or have you had a history of hypertension?
Do you have or have you had a history of ulcer disease?
Do you have hepatitis or liver disease?
Do you have diabetes?
Do you have kidney disease?
Do you have pancreatitis?
Do you have or have you had a history of epilepsy or seizures from withdrawal?
Do you have or have you had a history of Delirium Tremens - shakes?
Have you had a stroke?
Do you have or have you had a history of cancer?
Pregnant
If pregnant, are you seeking prenatal care?
Yes   No  
Are you currently taking any medication?
Yes   No  
Medication
  Name of Medicine What is the dosage? Frequency? Prescribing Physician?
1
2
3
4
5
6
7
8
9
10
Do you practice any complementary health approaches?
Massage   Chiropractic Care   Acupuncture  
Relaxation (such as deep breathing, guided imagery, progressive relaxation)   Dietary Supplements (such as Herbs, Probiotics, Vitamins/Minerals)   Yoga  
TaiChi   QiGong   Meditation  
Special Diet   Traditional healers (such as Chinese medicine or homeopathy)    
Do you have any allergies?
Yes   No  
List Allergies, if any.
Do you practice safe sex?
Do you have a Primary Care Physician (PCP)?
Yes   No  
If yes, who is your Primary Care Physician?
Primary Care Physician Phone:
Do you currently have any upcoming Dr appointments?
Yes   No  
Do you currently have mental health services in place?
Yes   No  
Is there a family history of mental illness and/or suicide?
Yes   No  
If yes, explain
Are you aware of any other medical issues that need attention?
Yes   No  
If yes, explain
Is there a family history of health concerns?
Yes   No  
If yes, explain
Substance Use
IV drug use in the last 30 days?    (If "YES", one of the substances HAS to be an IV drug
Are you currently attending 12 step meeting (AA/NA etc)?
Number of days attended AA/NA in last 30 days
On a scale of 1 to 5, with 1 = no problem and 5 = severe problem, how would you rate your alcohol/drug use?
Have you had any attempts to quit or reduce drinking or using?
Have you had any periods of complete abstinence?
If yes, reason/length of time?
Does Client Currently Use Tobacco
Daily Frequency of Cigarette Use
What substances are you currently using, how much, and how used? What substances have you used in the past and include how long ago and how much used and how used?
Prior Treatment History in Last 10 years    When, where, level, length, completed, length of abstinence
Where is most of your use done?
In the past 12 months, how many times have you driven under the influence?
What is the total number of arrests in the last 12 months?
How many OWI's have you had in the Last 12 Months?
How many arrests were related to non-drug or alcohol related crime while under the influence in the last 12 months?
How many arrests were related to non-drug or alcohol related crime while not under the influence in the last 12 months
How many arrests were related to drug or alcohol related crime in the last 12 months
How many arrests have occurred in past 30 days?
Are you interested in medication assisted treatment? (Examples include; Suboxone, Buprenorphine, Naloxone, Methadone, Anabuse)
If you are interested in medication assisted treatment, why and what are you interested in?
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