Medical History Application – Grace Like Rain

Medical History Application Form

Medical History for Application

Name *

Past Psychiatric and Mental Illness History

Have you been diagnosed with or treated for: *

Bipolar Disorder

Depression

Anxiety

Anger

Violence

Suicide

Schizophrenia

Post-traumatic Stress Disorder

Alcohol Abuse

Other Substance Abuse

None

Have you ever had Outpatient or Inpatient treatment? *

Yes, Inpatient

Yes, Outpatient

No, I have never received treatment

If yes, please describe when, by whom, and nature of treatment. Reason, Dates, Treatment, By Whom.

Have you ever received treatment for Psychiatric Care or Mental Illness? *

Yes

If yes, Please describe for what reason, when and where. Reason, Dates, Hospitalized Where?

Have you ever been prescribed psychiatric or mental illness medications? *

Yes

Antidepressants- Please indicate the dates, dosage, and how helpful they were.

Examples of Antidepressant medications are: Prozac, Zoloft, Luvox, Paxil, Celexa, Lexapro, Effexor, Cymbalta, Wellbutrin, Remeron, Serzone, Anafranil, Pamelor, Tofranil, Elavil.

Antipsychotics/Mood Stabilizers- Please indicate the dates, dosage, and how helpful they were.

Examples of Antipsychotics/Mood Stabilizer medications are: Seroquel, Zyprexa, Geodon, Abilify, Clozaril, Haldol, Prolixin, Risperdal, Sedative/Hypnotics Ambien, Sonata, Rozerem, Restoril, Desyrel.

Mood Stabilizers- Please indicate the dates, dosage, and how helpful they were.

Examples of Mood Stabilizer medications are: Tegretol, Lithium, Depakote, Lamictal, Topamax.

ADHD Medications- Please indicate the dates, dosage, and how helpful they were.

Examples of ADHD medications are: Adderall, Concerta, Ritalin, Strattera.

Antianxiety Medications- Please indicate the dates, dosage, and how helpful they were.

Examples of Antianxiety medications are: Xanax, Ativan, Klonopin, Valium, Tranxene, Buspar.

When did you last receive a mental health examination? *

Less than 6 months ago

6 months ago

A year ago

More than a year ago

Never

Family Psychiatric and Mental Illness History

Has anyone in your family been diagnosed with or treated for: *

Bipolar Disorder

Depression

Anxiety

Anger

Violence

Suicide

Schizophrenia

Post-traumatic Stress Disorder

Alcohol Abuse

Other Substance Abuse

None

If yes to any of the diagnoses above, please list below who was diagnosed and with what.

Has any family member been treated with a psychiatric or mental illness medication? *

Yes

If yes, who was treated, what medications did they take, and how effective was the treatment?

Substance Use

Have you ever been treated for alcohol or drug use or abuse? *

Yes

If yes, for which substances, where were you treated, and when?

How many days per week do you drink alcohol? *

What is the least number of drinks you will drink in a day? *

What is the most number of drinks you will drink in a day? *

In the past three months, what is the largest amount of alcoholic drinks you have consumed in one day? *

Have you ever felt the need to decrease the level of alcohol consumption? Has the level of alcohol consumption posed as problematic in your daily life? *

Yes

Have people annoyed you by critizing your drinking or drug use? *

Yes

Have you ever felt bad or guilty about your drinking or drug use? *

Yes

Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover? *

Yes

Do you think you may have a problem with alcohol or drug use? *

Yes

Have you used any street drugs in the past 3 months? *

Yes

If yes, which ones?

Have you ever abused prescription medication? *

Yes

If yes, which ones and for how long?

Check if you have ever tried the following: *

Methamphetamine

Cocaine

Stimulants (pills)

Heroin

LSD or Hallucinogens

Marijuana

Pain Killers (not as prescribed)

Methadone

Tranquilizers/Sleeping pills

Alcohol

Ecstasy

None

OtherOther

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