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Healing Dialogue LLC
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Introduction Form
Previous Medical Form
Personal and Interpersonal Form
Family Relationship Form
Family Medical History Form
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
Submit
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