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Please complete and bring this form to clinic

Name (last, first, mi):______________________________________________________ Age:_______ Date of Birth:________________________________________________ Address:________________________________________________________________ Home Phone:_______________ Work Phone:______________ Cell:________________ Date of appointment:_____________Who referred you?__________________________ Have you been treated here before?__________________________________________ What problem/s brings you to Florida Recovery Center Clinic? ________________________________________________________________________________________________________________________________________________ Please describe the major stressor(s) in your life now: ________________________________________________________________________________________________________________________________________________ Are you currently having any of the following problems? Have you received any inpatient or outpatient psychiatric care, counseling, therapy, or psychiatric medication management? Please describe below. Have you been treated with any of the following medications? Check all that apply. Which of these medications were particularly helpful, or problematic? ________________________________________________________________________________________________________________________________________________ Have you ever attempted suicide, or intentionally injured yourself? Please describe. ________________________________________________________________________________________________________________________________________________ Have you ever had treatment for substance abuse/dependence? Outpatient treatment Yes No Inpatient treatment Yes No If yes, please describe (type, when,where)______________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Regarding substance(s) listed above, have you ever experienced: Recurrent failure to fulfill duties at work/school/home? Using in situations that could be dangerous (e.g. driving a car)? Recurrent social or relationship problems (e.g. arguments with spouse)? Needing more and more to get the same effect? Less effect on same dose? Withdrawal symptoms when you stopped or reduced your dose? Taking more, or for a longer time, than you planned? Wanting, or trying unsuccessfully, to cut back or quit? Spending a great deal of time in activities surrounding the substance? Reducing important social/occupational/recreational activities because of the substance? Knowing that it was harming your physical or mental health and taking it anyway? Doing things that violate your own personal code of ethics (e.g. lying, stealing, etc.)? Do you currently have a primary care doctor? Name______________________________ Are you presently being treated for medical problems? If yes, for what problem and who is treating you?___________________________________________________________ ________________________________________________________________________________________________________________________________________________ When was your last physical examination?_____________________________________ Where and by whom?______________________________________________________ What major illnesses have you had I the past? ________________________________________________________________________________________________________________________________________________ What surgeries have you had? ________________________________________________________________________________________________________________________________________________ Have you had any serious injuries, including head injuries? Please explain. ________________________________________________________________________________________________________________________________________________ List all medications you are currently taking, including over the counter and herbal/natural preparations: Describe any allergic reactions to medications: ________________________________________________________________________________________________________________________________________________ Are you currently having any of these physical symptoms? When was your last menstrual period?_________________________________________ Do you currently use birth control? If yes, what kind? Any problems? ________________________________________________________________________ Are you currently pregnant? If not pregnant, are you trying to become pregnant? Yes No Have you experienced any of the following: Pregnancies Current Weight ________Highest________Lowest_______ Are you unhappy with your current weight? Do you have intense fear of becoming fat? Have you ever missed 3 menstrual cycles in a row? Have you ever restricted your eating below 1000 calories/day? Do you ever binge or lose control of how much you eat? Do you ever intentionally vomit after eating? Do you ever use laxatives, diuretics, or other drugs to lose weight? Have you had a significant weight gain in the past 6 months? Have you had a significant weight loss in the past 6 months? Please list the blood relatives who have suffered from the following illnesses or problems: Alcoholism: _____________________________________________________________ Abuse of illegal drugs:_____________________________________________________ Depression:______________________________________________________________ Manic depression/bipolar:___________________________________________________ Postpartum depression:_____________________________________________________ Schizophrenia:____________________________________________________________ Suicide:_________________________________________________________________ Cancer:_________________________________________________________________ Heart disease:____________________________________________________________ Diabetes: _______________________________________________________________ Osteoporosis:_____________________________________________________________ Strokes:_________________________________________________________________ Thyroid disease:__________________________________________________________ Indicate who currently provides social and emotional support to you: Who lives with you?_______________________________________________________ Are you currently having any problems with the persons that you live with? Yes No If yes, please explain:__________________________________________ Please indicate which of the following you experienced while you were growing up: What is the highest level of education you have achieved?_________________________ ________________________________________________________________________ What jobs/occupations have you had?_________________________________________ ________________________________________________________________________ ________________________________________________________________________ Are you currently employed? Where do you work, and what is your occupation? _______________________________ ________________________________________________________________________ How long have you been at current employment?________________________________ Are you experiencing any problems at your job?_________________________________ ________________________________________________________________________ If not employed, how do you support yourself?__________________________________ ________________________________________________________________________ Are finances are a cause of stress for you? How?________________________________ ________________________________________________________________________ How many times have you been: Married?______ Divorced?______ Widowed?_______ What is your present marital status?___________________________________________ Do you have any problems or concerns about your current intimate relationship? ________________________________________________________________________ How many children do you have?____________________________________________ Do any of children live with you? Please summarize your spiritual or religious beliefs:______________________________ ________________________________________________________________________ Do you belong to a congregation or formal religion? Which?_______________________ How important are your spiritual/religious beliefs/affiliation?______________________ ________________________________________________________________________ Do you feel unsafe in your current environment? If no, please describe your concerns_____________________________________ ________________________________________________________________________ Do you have access to any firearms in your home? Do you currently have thoughts/plans of hurting anyone else? Do you currently have thoughts/plans of hurting yourself? Have you experienced any significant losses or changes (such as deaths, divorce, relocations, unemployment) that may be contributing to your current problems? Please explain. ___________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Have you ever been the victim of a violent crime? _______________________________ ________________________________________________________________________ Have you ever witnessed a severe act of violence?_______________________________ ________________________________________________________________________ Have you been the victim of physical abuse?____________________________________ ________________________________________________________________________ Have you ever been a victim of rape or sexual assault?____________________________ ________________________________________________________________________ Have you ever been a victim of childhood sexual abuse?__________________________ ________________________________________________________________________ Please list your favorite activities/hobbies:______________________________________ ________________________________________________________________________________________________________________________________________________ Please rate the current level of stress in your life by placing an “x” on the lines below. Job/Employment

Source: https://m.ufhealth.org/sites/default/files/media/Locations/psychiatry-springhill/AddictionsIntakePacket.pdf

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