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 Rapids Hibbing Aitkin International Falls Client Name First Last Date of Birth MM slash DD slash YYYY AgeHeight 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 NumberPrimary 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: MedicalDate of last physical exam MM slash DD slash YYYY Medication Allergies Yes No List Medication AllergiesOther Allergies Yes No List Other AllergiesMedication side effects Yes No List the medication and the side effectSupplemental Medicinal Treatment (St. Johns wort, herbs, vitamins) Yes No Types of medicinal treatment usedFamily 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 quantityTobacco (smoke/chew) Yes No Type and daily quantityDo you eat regular meals? Yes No Describe meals if yesDo you exercise Yes No List type and how oftenWomenCurrently pregnant Yes No Due Date MM slash DD slash YYYY Regular periods Yes No If no, please explainMedicationPlease list your current medications (include the name and dose)Mental HealthHave 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)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.