Mount Vernon Psychological Services
This information is to help the staff develop treatment goals that are complete and effective. It is important that
the information you report to us is accurate. We recognize that some of this information is sensitive. This
information will remain confidential. Exceptions are explained on the Consent To Treat Form detail.. If there
are concerns about this information you are sharing, you should discuss them with your counselor before
completing this form.
DATE
Birth Date:________________ Age: _______ Sex: ___M ___F
NAME
SSN:______________________
Address:
City:
State:
Zip:
DO YOU HAVE ANY MEDICATION ALLEGIES OR REACTIONS? [ ] YES [ ] NO
IF YOU MARKED YES, PLEASE LIST:
CHECK HERE IF YOU HAVE RECENTLY HAD THESE SYMPTONS:
Trembling, twitching, feeling shaky
Shortness of breath or smothering sensation
Chest Pain
Racing heart or heart palpitations
Moist palms or excessive sweating
Dizziness, lightheadedness or blackouts
Nausea, diarrhea or other abdominal distress
Flushes, chills or hot flashes
Numbness or tingling sensations
Periods of inflated self-esteem or excessive
self-importance
Excessive involvement in pleasurable activity
(such as sex or spending) which results in
major problems
Periods of purposeful but excessive activity
Unusually long periods of high energy or
activity without the need for rest
Excessive hand washing or fear of
Trouble swallowing, “lump in throat” or choking sensation
Times of feeling that you or things around you are not real
Excessive checking (doors, locks, stoves)
Annoying thoughts that won’t go away
Self induced vomiting
Binge eating
Excessive exercises
Excessive exercises
Use of laxatives /diuretics (circle one / both)
Strict dieting
Careless mistakes in work, school, etc.
Can only pay attention for short periods of time
at work, school or home
Failure to complete school work,
germs
Frequent headaches or other muscle aches
Restlessness
Dry Mouth
Frequent Urination
Nervousness or feeling edgy
Startle easily
Irritability (lose temper easily)
Worrying a lot
Excessive or unreasonable fears
Difficulty concentrating or poor memory
chores, etc.
Tire easily or low energy level
Increased or Decreased sleep (circle which applies)
(Average hours per night
)
Loss of interest in many or most activities
Increased or decreased appetite (circle which applies)
(Amount of weight change
)
Feelings of hopelessness
Often loses things necessary for tasks
None of the above
Hyperactive: fidgets, squirms, talks excessively
Acts without considering consequences
Forgetful in daily activities
Daydreams frequently
Difficulty organizing tasks and activities
Is easily distracted by extraneous stimuli
Mount Vernon Psychological Services
List major operations, serious injuries, hospitalizations:
None
Date
Present Condition
Describe
Have you ever suffered from a head injury?
Yes
No
If yes, when?
Did you lose consciousness?
List current medications, both prescription and over the counter:
Name of Medication
Amount / Dosage
Frequency
Purpose
Describe any side effects from the medications listed above:
List any medications taken in the past:
Do you work around chemicals?
Yes
No If yes, please list the chemicals:
Do you believe you have a problem with alcohol or drugs?
If yes, which substances are a problem for you?
Yes
No
Please indicate the amount of each consumed daily:
Caffeine:
Cups of Coffee
Cups of Caffeinated Tea
Glasses of Caffeinated Soft Drinks
How much alcohol do you consume and how often do you drink?
How Much
How Often
Beer
Wine
Liquor
Nicotine: Packs of cigarettes daily
Other nicotine used
Please check any of the following symptoms you may be currently experiencing:
Sexual difficulties
Burning or itching urination
For Females:
PMS (Premenstrual Syndrome)
Mount Vernon Psychological Services
Loss of control of urine
Menstrual difficulties or change
Swollen feet or ankles
Unusual vaginal discharge
Coughing up blood
Bleeding between periods
Unusual lumps or swelling
Number of pregnancies:
Trouble stopping bleeding/frequent nosebleeds
Are you currently pregnant or is it possible that
Problems hearing or ringing in ears
you might be pregnant? [ ] Yes [ ] No
Problems with vision
Snoring
For Males:
Pain in
Burning or discharge from penis
NONE
Prostate problems
Have you been sexually assaulted? [ ] YES
[ ] NO
Physically abused? [ ] YES
[ ] NO
Name of Primary Physician:
Date of last physical exam?
Other Physicians:
Please indicate the amount of health care utilization in the past 12 months:
Hospital admissions
Emergency Room visits
Outpatient Health Care admissions / visits
Regular visits to doctor / dentist (preventive)
Please check any medical conditions your physicians have diagnosed:
Past
Now
Past
Alcoholism
Anemia (type
Arthritis
Asthma
Cancer (type
Cirrhosis
Colitis
Ulcer
Depression
Diabetes
Other
Fibromyalgia
Heart Condition
Hepatitis
High Blood Pressure
Migraine Headaches
Multiple Sclerosis
Pancreatitis
Seizures
Thyroid Condition
Lupus
)
)
What type of exercise do you get?
Are you on a special diet? [ ] Yes
How often?
[ ] No
If yes, please give details:
Which of the following have you used?
Current (past 3 months)
Heroin
Barbituates
Amphetamines
Methamphetamines
Crack
Cocaine
Marijuana/Hashish
Now
None
Past
None
Mount Vernon Psychological Services
LSD
Inhalants
Valium
PCP
Prescriptions Drugs
Over the Counter Drugs
Non-Prescription Drugs by injection
Please list previous counseling, psychiatric, hospitalization and alcohol or drug rehabilitations:
Date:
Reason:
Family Health History:
Check all illnesses and diseases that your family members have suffered from and which relative suffers from
this ailment (mother, father, siblings, grandparents, aunts, uncles, etc.)
Relationship
A degenerative disease
Alcoholism
Allergies
Cancer
Diabetes
Obesity
Suicide
Nervous Breakdown
Relationship
Drug Addiction
Epilepsy
Heart Trouble
High Blood Press
Mental Illness
Stroke
Thyroid Problems
None
Do you have any physical problems or disabilities this question has not addressed? Please describe:
Legal History:
Client Signature
Guardian Signature
I have chosen NOT to complete this form.
Medical Personnel Signature
Date
Date
Date
Date