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Print Form Client #

SEACOAST MENTAL HEALTH CENTER, INC. CLIENT PROVIDED MEDICAL SCREENING Client Name: Health Screening: (please check) Do you have MEDICATION ALLERGIES? Do you use tobacco products?

Date of Birth: No

Yes

Date:

if “yes� please explain

Do you consume/use caffeine? Do you use alcohol or recreational drugs? Have you ever received treatment for drug/alcohol problems? Do you have any physical symptoms, complaints, illnesses, recent hospitalizations, or extended medical absences from work?

Where, when? If yes, are you receiving treatment? Please explain.

Do you have any dental symptoms, complaints, or illnesses?

If yes, are you receiving treatment? Please explain.

Do you have any childhood developmental problems (low birth weight, trauma during birth, developmental delays, fetal alcohol/drug exposure, etc.)? Are you currently experiencing any acute or chronic pain?

If yes, how do these impact on current functioning?

Do you have any chronic illnesses or other significant medical history we should know?

If yes, please explain.

If yes, are you receiving treatment? Please explain.

Name of: Primary Care Practitioner: Address: Dentist: Previous Psychiatrist:

Last Appointment: Phone: Last Appointment: Last Appointment:

Medications: List any prescription medications, over-the-counter medications, vitamins, or dietary supplements you are now taking: Dose Name Dose Name

QI Approved: 9/13/01

Rev. 11/04

File: Medical Section


Client #

Nutritional screening: (please check) Has a professional recommended that you be on a special diet? Do you consider yourself either over or underweight?

No

Yes if “yes� please explain.

Has your weight recently changed? Has your appetite recently changed? Family History: Please indicate if you, a parent, or a sibling have or have had any of the following illnesses: Illness No Yes Who? Illness No Yes Who? High blood pressure Enlarged prostate Diabetes Mental illness Glaucoma Alcoholism/drug dependence Ulcers Tuberculosis Lung disease Heart Disease Thyroid disease Cancer Kidney disease Seizure disorder Head injury Sexually transmitted disease Digestive problems HIV/AIDS (Crohn's disease, Irritable Hepatitis bowel, colitis) Other (specify)

Tuberculosis Screening: Have you had any of the following symptoms in the past year? No Yes Productive cough lasting more than 2 weeks? Coughing up blood or bloody sputum? Significant weight loss without dieting? Significant weakness? Significant night sweats? Significant fever? Significant loss of appetite?

Client Signature

Women - OB/GYN Screening: Date of last Pap Smear: Date of last mammogram: Date of last menstrual period: History of pregnancy, miscarriage, abortion:

SMHC Clinician Signature

Office use only

No outstanding physical problems requiring further evaluation/assessment or treatment indicated, based on above information. Further information needed: Additional information about Clearance from Dr. Records from Dr. A physical exam/assessment is recommended. The following labs or tests must be completed:

Psychiatrist Signature

QI Approved: 9/13/01

. needs to be obtained. need to be obtained.

Date

Rev. 11/04

File: Medical Section

Client Provided Medical Screening  

Client Provided Medical Screening

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