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Previous Medical History Form

First name

Last name

Check if you have experienced any of the following

Emotional Abuse

Parent Substance Abuse

Violence in House

Placed a Child up for Adoption

Homelessness

Sexual Abuse

Teen Pregnancy

Crime Victim

Lived in Foster Home

Loss of Loved One

Physical Abuse

Neglect

Parent Illness

Multiple Family Moves

Financial Problems

Previous Mental Health Treatments

Outpatient Counseling Date

Month

Day

Year

Outpatient Counseling Provider/Program

Outpatient Counseling Reason

Medication for Mental Health Date

Month

Day

Year

Mental Health Provider/Program

Mental Health Reason

Psychiatric Hospitalization Date

Month

Day

Year

Psychiatric Hospitalization Provider/Program

Psychiatric Hospitalization Reason

Drug/Alcohol Treatment Date

Month

Day

Year

Drug/Alcohol Treatment Provider/Program

Drug/Alcohol Treatment Reason

Self-Help/Support Groups Date

Month

Day

Year

Self-Help/Support Groups Provider/Program

Self-Help/Support Groups Reason

Physical Medical History

Date of Last Physical Exam

Month

Day

Year

Experienced Medical Conditions (over lifetime)

Allergies

Sexually Transmitted Diseases

Diabetes

Seizures

Head Injury

Chronic Pain

Asthma

Abortion

Hearing problems

Vision problems

Dizziness/Fainting

Surgery

Headaches

Sleep Disorder

Miscarriage

High Fevers

Meningitis

Serious Accident

Stomach Aches

Other Experienced Medical Conditions (over lifetime)

List any Current Medical Concerns

Medication

Medication 1 Name, Dosage, Date Prescribed, Prescribed By

Medication 2 Name, Dosage, Date Prescribed, Prescribed By

Medication 3 Name, Dosage, Date Prescribed, Prescribed By

Medication 4 Name, Dosage, Date Prescribed, Prescribed By

List any Over The Counter Medications (vitamins, herbal, etc)

List any allergies or allergic reactions

Healing Dialogue LLC

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