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 & GAD 7. Thank you. Adult Health Questionnaire Location for which you would like your services at:Grand RapidsHibbingAitkinInternational FallsClient Name First Last Date of Birth Date Format: MM slash DD slash YYYY AgeHeightWeightDo you have a health care directive?YesNoI do not knowIn case of an emergency please notify:RelationshipEmergency Contact Phone NumberPrimary Care Physician First Last Primary Care Clinic or HospitalPharmacyReason for Contacting Northland Counseling Center, Inc?Referred by:Current Therapist if you have one:MedicalDate of last physical exam Date Format: MM slash DD slash YYYY Medication Allergies Yes No List Medication AllergiesOther Allergies Yes No List Other AllergiesMedication side effectsYesNoList the medication and the side effectSupplemental Medicinal Treatment (St. Johns wort, herbs, vitamins)YesNoTypes of medicinal treatment usedFamily history of thyroid issues?YesNoIf yes, please explain.Head/Brain injuries, seizure, stroke, concussion or loss of consciousness?YesNoIf yes, please explain.Current treatment for medical condition/infectionYesNoExplain if yes.Past medical problemsYesNoList if yes:Pain which interferes with daily activitiesYesNoIf yes, please list.Recent significant weight gain/lossYesNoHow much if yes and reason if known.Caffeine ConsumptionYesNoType and daily quantityTobacco (smoke/chew)YesNoType and daily quantityDo you eat regular meals?YesNoDescribe meals if yesDo you exerciseYesNoList type and how oftenWomenCurrently pregnantYesNoDue Date Date Format: MM slash DD slash YYYY Regular periodsYesNoIf no, please explainMedicationPlease list your current medications (include the name and dose)Mental HealthHave you had a diagnostic assessment within the past year?YesNoI do not knowIf 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)CommentPerson 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 correctIf you do not receive a call from a staff within 2 days of submitting your paperwork please contact your local Northland Counseling Center location to ensure they have received your paperwork. Please ensure you click submit.