Health Information Form Health Form Rate your health (check)Very GoodGoodAverageDecliningWeight Changes recentlyLostGainedList all important present or past illnesses, injuries or handicapsDate of last medical exam Date Format: MM slash DD slash YYYY ResultsYour PhysicianAddressAre you presently taking medication?YesNoPlease ListHave you ever been convicted of a crime?YesNoCircumstancesAre you willing to sign a release form so that your counselor may write for social, psychiatric, or medical reports?YesNoHave you used drugs for other than medical purposes?YesNoDescribeHave you ever had a severe emotional upset or trauma?YesNoDescribeHave you ever had any psychotherapy or counseling before?YesNoIf yes, please name counselor or therapist and datesWhat was the outcome?Driver’s License or IDInsurance Card front and backReligious BackgroundDenominational PreferenceDenomination of church attended in childhood?Baptized?YesNoWhen?Religious background of spouse (if married)Do you believe in God?YesNoUncertainHow frequently do you read the bible?NeverOccasionallyOftenAre you saved?YesNoNot sure what that meansDo you have regular family devotions?YesNoExplain recent changes in your religious life, if anyDo you attend church?YesNoHow often per month 0 1 2 3 4 5 6 7 8 9+Reason for Seeking Counseling Briefly answer the following questions: What problem brings you here?What have you done about it?What would you like us to focus on? (What are your expectations?)What brings you here at this time?Is there any other information we should know?
