Brief Health Information Form If something doesn’t apply put NA. Thanks!

A. Identification 
Client’s name: __________________________________________ Case #: ___________ Date: _________

B. History 
1. Starting with your childhood and proceeding up to the present, list all diseases, illnesses, important accidents and 
in­juries, surgeries, hospitalizations, periods of loss of consciousness, convulsions/seizures, and any other medical 
con­ditions you have had. (Describe pregnancies in section E.) 

Age 		Illness/diagnosis 		Treatment received 			Treated by 			Result_______________ 

2. Describe any allergies you have. 
To what? 					Reaction you have 						Allergy medications you take_____________

 
3. List all medications, drugs, or other substances you take or have taken in the last year—prescribed, over-the-­counter vitamins, herbs, and others. 
									Dose (how 
Medication/drug 					much?) 			Taken for				Prescribed and supervised by______

Have you done any kinds of work where you were exposed to toxic chemicals? 
Date 		Kinds of chemicals 						Kind of work 					Effects__________________ 

C. Medical caregivers 
1. Your current family or personal physician or medical agency: 
																											Date of 
Name 								Specialty 			Address 							Phone # 		last visit

 
2. Other physicians treating you at present or in last 5 years: 
																											Date of 
Name 								Specialty 			Address 							Phone # 		last visit

D. Health habits 
1. What kinds of physical exercise do you get? ________________________________________________________
_______________________________________________________________________________________________ _______________________________________________________________________________________________

2. How much coffee,cola,tea,or other sources of caffeine do you consume each day? Which? _____________________
_______________________________________________________________________________________________

3. Do you try to restrict your eating in any way? 
How? __________________________________________________________________________________________
Why? __________________________________________________________________________________________

4. Do you have any problems getting enough sleep?  ❑ No ❑ Yes. If yes, what problems?  _____________________
______________________________________________________________________________________________

E. For women only 
At what age did you start to menstruate (get your period): _______
2. Menstrual period experiences: 
a. How regular are they? ___________________________________________________________________________
b. How long do they last? __________________________________________________________________________
c. How much pain do you have? _____________________________________________________________________
d. How heavy are your periods? _____________________________________________________________________
e. Other experiences during periods? _________________________________________________________________
Please list all of your pregnancies: 
			What happened with this pregnancy? 			
Your age 	Miscarriage		Abortion	Child born						Problems? 	 
1. 
2. 
3. 
4. 
5. 
6. 					

4. Menopause: 
a. If your menopause has started, at what age did it start? __________________
b. What signs or symptoms have you had? ____________________________________________________________
_______________________________________________________________________________________________ _______________________________________________________________________________________________

F. Other 
Do you use tobacco  ❑ No  ❑ Yes.  Yes. If yes, how many cigarettes/cigars/other do you use each day? _________
Have you ever injected drugs? ❑ Yes   ❑ No Ever shared needles?  ❑ Yes   ❑ No 
Have you had HIV testing in the last 6 months?  ❑ Yes   ❑ No. If yes, results: _________________________________
Are there any other medical or physical problems you are concerned about? ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________