Health Information Form Health Form Name* Email* Rate your health (check) Very Good Good Average Declining Weight Changes recently Lost Gained List all important present or past illnesses, injuries or handicapsDate of last medical exam MM slash DD slash YYYY ResultsYour Physician Address Are you presently taking medication? Yes No Please List Have you ever been convicted of a crime? Yes No Circumstances Are you willing to sign a release form so that your counselor may write for social, psychiatric, or medical reports? Yes No Have you used drugs for other than medical purposes? Yes No Describe Have you ever had a severe emotional upset or trauma? Yes No Describe Have you ever had any psychotherapy or counseling before? Yes No If yes, please name counselor or therapist and dates What was the outcome? Religious BackgroundDenominational Preference Denomination of church attended in childhood? Baptized? Yes No When? Religious background of spouse (if married) Do you believe in God? Yes No Uncertain How frequently do you read the bible? Never Occasionally Often Are you saved? Yes No Not sure what that means Do you have regular family devotions? Yes No Explain recent changes in your religious life, if anyDo you attend church? Yes No How 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?