Health History Form – Behavioral Health

Please print and fill out as completely as possible
Date*
MM slash DD slash YYYY
Patient's Full Name*
First Middle Last
Date of Birth
MM slash DD slash YYYY
Place of Birth
Gender
- Male
- Female
- Transgender Male (Female to Male)
- Transgender Female (Male to Female)
- Other
- Choose not to disclose
- Queer (neither exclusively male nor female)
If the patient is a MINOR (under the age of 18) please complete information below. Guardians are required to submit guardianship documents.
Patient's Parent/Guardian Name
Relationship to the patient
- Mother
- Father
- Guardian
Marital Status
- Single
- Married
- Divorced
- Widowed
- Other
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone Number*
Email
Number of children*
Ages of children*
Occupation*
Employer*
MEDICAL HISTORY:
Are your influenza immunizations current?*
- Yes
- No
- Unsure
Are your pneumovax immunizations current?*
- Yes
- No
- Unsure
Have you been diagnosed as diabetic?*
- Yes
- No
If yes, date of diagnosis*
MM slash DD slash YYYY
Do you have latex sensitivity or allergy?
- Yes
- No
- Other
Are you allergic to?*
- Penicillin
- Local Anesthetic
- Codeine
- Asprin
- None
- Other
- Other Antibiotic
Please describe:
Have you ever received a colorectal cancer screening?*
- Yes
- No
If yes, when*
MM slash DD slash YYYY
Are you presently taking any medications/drugs/pills that include over-the-counter medications and dietary supplements?*
- Yes
- No
If yes, list all medications/drugs/pills including over-the-counter medications and dietary supplements.
Do you have ANY allergies? This includes food, environmental, etc.
- Yes
- No
- Unsure
If yes, list all allergies:
Do you have any medication allergies?
- Yes
- No
- Unsure
If yes, list all allergies:
Have you had any past surgeries?*
- Yes
- No
If yes, list all surgeries and date of surgery:*
Do you have, or have you had any of the following: (Yes or No)
Abnormal Blood Pressure
- Yes
- No
Alcohol Addiction
- Yes
- No
Anemia
- Yes
- No
Anorexia
- Yes
- No
Arthritis/Rheumatism
- Yes
- No
Artificial Heart Valve
- Yes
- No
Artificial Joint
- Yes
- No
Asthma
- Yes
- No
Bulimia
- Yes
- No
Cancer
- Yes
- No
Chemical Dependency
- Yes
- No
Chemotherapy
- Yes
- No
Congenital Heart Disease
- Yes
- No
Cortisone Medicine
- Yes
- No
Diabetes
- Yes
- No
Recreational Drugs
- Yes
- No
Emphysema
- Yes
- No
Epilepsy
- Yes
- No
Fainting Spells
- Yes
- No
Glaucoma
- Yes
- No
Hearing Impaired
- Yes
- No
Heart Disease/Surgery
- Yes
- No
Heart Murmur
- Yes
- No
Heart Pacemaker
- Yes
- No
Hemophilia
- Yes
- No
Hepatitis
- Yes
- No
HIV Positive / AIDS
- Yes
- No
Kidney Problems
- Yes
- No
Learning Disability
- Yes
- No
Liver Disease
- Yes
- No
Lung Disease
- Yes
- No
Mitral Valve Prolapse
- Yes
- No
Neurological Disorders
- Yes
- No
Organ Transplant
- Yes
- No
Osteoporosis
- Yes
- No
Prolonged Bleeding
- Yes
- No
Prosthetic Implants
- Yes
- No
Psychiatric Care
- Yes
- No
Radiation Therapy
- Yes
- No
Removal of Spleen
- Yes
- No
Rheumatic Heart Disease
- Yes
- No
Sickle Cell Disease
- Yes
- No
Sinus Trouble
- Yes
- No
Stroke
- Yes
- No
Thyroid Problems
- Yes
- No
Tuberculosis
- Yes
- No
Tumors
- Yes
- No
Ulcers
- Yes
- No
Sexually Transmitted Infection
- Yes
- No
FEMALE MEDICAL HISTORY:
Have you ever received a pap screening?
- Yes
- No
If yes, when
MM slash DD slash YYYY
Where
Last menstrual period:
MM slash DD slash YYYY
Pregnancy history
- never been pregnant
- abortion(s)
- miscarriages
- tubal pregnancies
- live births
Are you pregnant?
- Yes
- No
Are you nursing?
- Yes
- No
If yes, when:
Have you ever received a mammography screening?
- Yes
- No
Where
FAMILY HISTORY:
Mother*
- living
- deceased
If deceased, please list reason
Age*
Please identify any of the following with the family member above
- Alcoholism
- High Blood Pressure
- Cancer
- High Cholesterol
- Diabetes
- Obesity
- Mental Health Disorders
- Stroke
- Heart Disease
- Tuberculosis (TB)
Father*
- living
- deceased
If deceased, please list reason
Age*
Please identify any of the following with the family member above
- Alcoholism
- High Blood Pressure
- Cancer
- High Cholesterol
- Diabetes
- Obesity
- Mental Health Disorders
- Stroke
- Heart Disease
- Tuberculosis (TB)
If deceased, please list reason (Grandmothers)
If deceased, please list reason (Grandfathers)
Sibling 1
- living
- deceased
If deceased, please list reason
Please identify any of the following with the family member above
- Alcoholism
- High Blood Pressure
- Cancer
- High Cholesterol
- Diabetes
- Obesity
- Mental Health Disorders
- Stroke
- Heart Disease
- Tuberculosis (TB)
Sibling 2
- living
- deceased
If deceased, please list reason
Please identify any of the following with the family member above
- Alcoholism
- High Blood Pressure
- Cancer
- High Cholesterol
- Diabetes
- Obesity
- Mental Health Disorders
- Stroke
- Heart Disease
- Tuberculosis (TB)
Sibling 3
- living
- deceased
If deceased, please list reason
Please identify any of the following with the family member above
- Alcoholism
- High Blood Pressure
- Cancer
- High Cholesterol
- Diabetes
- Obesity
- Mental Health Disorders
- Stroke
- Heart Disease
- Tuberculosis (TB)
Child 1
- living
- deceased
If deceased, please list reason
Please identify any of the following with the family member above
- Alcoholism
- High Blood Pressure
- Cancer
- High Cholesterol
- Diabetes
- Obesity
- Mental Health Disorders
- Stroke
- Heart Disease
- Tuberculosis (TB)
Child 2
- living
- deceased
If deceased, please list reason
Please identify any of the following with the family member above
- Alcoholism
- High Blood Pressure
- Cancer
- High Cholesterol
- Diabetes
- Obesity
- Mental Health Disorders
- Stroke
- Heart Disease
- Tuberculosis (TB)
Child 3
- living
- deceased
If deceased, please list reason
Please identify any of the following with the family member above
- Alcoholism
- High Blood Pressure
- Cancer
- High Cholesterol
- Diabetes
- Obesity
- Mental Health Disorders
- Stroke
- Heart Disease
- Tuberculosis (TB)
SOCIAL HISTORY:
Do you smoke cigarettes?
- Yes
- No
If yes, number of packs a day:
Number of years:
Other types of tobacco
- Pipe
- Snuff
- Cigar
- Chew
- E-Cigarette (E-Cig)
- Other
If yes, number of times a day:
Number of years:
Do you use drugs?
- Yes
- No
If yes, type:
Number of uses per week:
Do you use drink alcohol?
- Yes
- No
Are you sexually active?
- Yes
- No
If yes, sexual partner?
- Male
- Female
- Both
Method of birth control (if sexually active)
Would you like to be given a HIV test? (Results are strictly confidential)
- Yes
- No
Has anyone, including you partner ever forced you to have sexual activity against your will?
- Yes
- No
Has anyone, including your partner, ever threatened or abused you or your children physically, emotionally, or sexually?
- Yes
- No
May we refer you to a victim service advocate regarding the issue above?
- Yes
- No
DENTAL HISTORY:

Please answer the following (Yes or No):
Do your gums bleed while brushing or flossing?
- Yes
- No
Are your teeth sensitive to hot or cold liquids/foods?
- Yes
- No
Are your teeth sensitive to sweet or sour liquids/foods?
- Yes
- No
Do you feel pain to any of your teeth?
- Yes
- No
Do you have any sores or lumps in or near your mouth?
- Yes
- No
Have you had any head, neck or jaw injuries?
- Yes
- No
Do you have frequent headaches?
- Yes
- No
Do you clench or grind your teeth?
- Yes
- No
Do you bite your lips or cheeks frequently?
- Yes
- No
Have you ever experienced any of the following? Clicking in jaw, Pain (joint, ear side of face), Difficulty in opening or closing mouth, or Difficulty in chewing
- Yes
- No
Have you had any orthodontic work?
- Yes
- No
Have you ever had prolonged bleeding following extractions?
- Yes
- No
Have you ever had instruction on the correct method of brushing your teeth?
- Yes
- No
Have you ever had instructions on the care of your gums?
- Yes
- No
Comments:
FOR MINORS (under age 18):
Patient Name*
Patient Signature or Legal Representative:
First Name*
Last Name*
Email*
Date*
MM slash DD slash YYYY
Guardians and Legal Guardians are required to provide supporting documents
Provider Signature:

Signature:

Date:

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Health History Form – Behavioral Health

MEDICAL HISTORY:

FEMALE MEDICAL HISTORY:

FAMILY HISTORY:

SOCIAL HISTORY:

DENTAL HISTORY:

FOR MINORS (under age 18):

Patient Signature or Legal Representative:

Provider Signature: