Submit
Cancel

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 do you have a history of rheumatic fever?
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 have an advance directive?
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
Substance Use History    (Please use the scroll bar at the bottom of this chart to complete all columns in the chart.)
  Have you ever used? Age of First Use Primary Method of Use Other Method of Use Last Date of Use Amount Used (Frequency) Was this prescribed to you? Comments
Alcohol
Cocaine/Crack
Marijuana/Hashish
Heroin
Non-Prescription Methadone
Other Opiates/Synthetics
PCP
Other Hallucinogens
Methamphetamines
Other Amphetamines
Other Stimulants
Benzodiazepines
Other Tranquillizers
Barbiturates
Other Sedatives/Hypnotics
Inhalants
Over the Counter Medications
Steroids
Ecstasy
Oxycontin
Other Prescribed Analgesics
Other
IV drug use in the last 30 days?
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?
Other Addictions (1)
Other Addictions (2)
Other Addictions (3)
Other Addictions (4)
Does Client Currently Use Tobacco
Daily Frequency of Cigarette Use
Prior Treatment History in Last 10 years    When, where, level, length, completed, length of abstinence
Number of Prior SA Treatment Admissions within the Past 10 Years
Last SA Environment in Last 10 Years
Number of Days of Work/School Missed in Last 6 Months Due to Substance Abuse
Where is most of your use done?
In the past 12 months, how many times have you driven under the influence?
Number of arrests
Number of arrests in past 30 days
OWI in the Last 12 Months
Non-drug or alcohol related crime while under the influence in the last 12 months
Non-drug or alcohol related crime while not under the influence in the last 12 months
Drug or alcohol related crime in the last 12 months
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?
Form Updates
Name Date Action
    Form Started
  1. Click the "Submit" button to save the data entered on this form.
  2. Click the "Save and Exit" button to save recent updates and exit the form.
  3. Click the "Save and Print" button to save recent updates and print the form.
  4. Click the "Cancel" button to exit without saving recent updates on this form.