Adult Health Questionnaire

Thank you for choosing Northland Counseling Center. Please fill out the below form. Remember to fill out these additional forms: Adult Registration Form, GAIN-SS, PHQ-9 & WHODAS. Thank you.

Adult Health Questionnaire

Client Name
First Last
Date of Birth
Date Format: MM slash DD slash YYYY
Age
Height
Weight
Do you have a health care directive?
- Yes
- No
- I do not know
In case of an emergency please notify:
Relationship
Emergency Contact Phone Number
Primary Care Physician
First Last
Primary Care Clinic or Hospital
Pharmacy
Reason for Contacting Northland Counseling Center, Inc?
Referred by:
Current Therapist if you have one:
Medical
Date of last physical exam
Date Format: MM slash DD slash YYYY
Medication Allergies
- Yes
- No
List Medication Allergies
Other Allergies
- Yes
- No
List Other Allergies
Medication side effects
- Yes
- No
List the medication and the side effect
Supplemental Medicinal Treatment (St. Johns wort, herbs, vitamins)
- Yes
- No
Types of medicinal treatment used
Family history of thyroid issues?
- Yes
- No
If yes, please explain.
Head/Brain injuries, seizure, stroke, concussion or loss of consciousness?
- Yes
- No
If yes, please explain.
Current treatment for medical condition/infection
- Yes
- No
Explain if yes.
Past medical problems
- Yes
- No
List if yes:
Pain which interferes with daily activities
- Yes
- No
If yes, please list.
Recent significant weight gain/loss
- Yes
- No
How much if yes and reason if known.
Caffeine Consumption
- Yes
- No
Type and daily quantity
Tobacco (smoke/chew)
- Yes
- No
Type and daily quantity
Do you eat regular meals?
- Yes
- No
Describe meals if yes
Do you exercise
- Yes
- No
List type and how often
Women
Currently pregnant
- Yes
- No
Due Date
Date Format: MM slash DD slash YYYY
Regular periods
- Yes
- No
If no, please explain
Medication
Please list your current medications (include the name and dose)
Mental Health
Have you had a diagnostic assessment within the past year?
- Yes
- No
- I do not know
If yes, who was the provider and the agency? We will not contact them without your permission.
Please list the locations you have receive Mental Health services (Type - ex Out-patient; Facility, Date and Reason)
Please list the locations you have receive Chemical Dependency (CD) Treatment (Type - ex Out-patient; Facility, Date and Reason)
Comment
Person who is filling out this form
First Last
By checking this box you are acknowledging that all information presented is true to the best of your knowledge.
I agree that all information is true and correct

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Monday – Thursday: 8:00am to 5:00pm
Friday: 8:00am to 12:00pm

215 SE 2nd Avenue
Grand Rapids, MN 55744

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Northland Counseling Center

April 6, 2017

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Northland Counseling Center Inc. does not discriminate in the provision of services to individuals based on their inability to pay, race, color, sex, national origin, disability, religion, or sexual orientation. It is the policy of Northland Counseling Center to provide essential medical services regardless of the patient’s ability to pay. Discounts are offered based upon household income and size. A sliding fee schedule is used to calculate the basic discount and is updated each year using the federal poverty guidelines. Northland Counseling Center Inc. accepts Medicare, Medicaid, private and CHIP. We will work with you to determine insurance eligibility.

Adult Health Questionnaire