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Kiesler Wellness Center

Health Questionnaire (HQ) Ages 0-10

Thank you for choosing Northland Counseling Center! Please fill out the form below and once completed please make sure to also fill out Minor Registration Form, SDQ Parent Form. Authorization to treat a Minor & Telemedicine Form. Once completed an intake staff will contacting you.

Age 0-10 Health Questionnaire Intake

Today's date
Date Format: MM slash DD slash YYYY
Location of Services:
- Grand Rapids
- Hibbing
- Aitkin
Client Name
First Middle Last
Date of Birth
Date Format: MM slash DD slash YYYY
Age
Height
Weight
Sex of patient:
- Male
- Female
- Other
Name of Parents/Gaurdians:
First Last
Name of Parents/Gaurdians:
First Last
Relationship of person completing this form
School
Name of current school/program
School Grade
504/IEP Plan:
- Yes
- No
- I am not sure
504 Plan/IEP if yes, please explain
Medical
Primary Care Physician
First Last
Primary Care Clinic or Hospital
Please state the last appointment with a Primary Care Physician
Date Format: MM slash DD slash YYYY
Pharmacy
Are you currently being treated for any illness? If yes, please explain.
Do you have any medical and/or surgical history? If yes, please explain.
Are you currently taking and medicatons? If yes, please list name of medications and dose.
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:
Recent significant weight gain/loss
- Yes
- No
How much if yes and reason if known.
Substance Use
Tabacco/Nicotine
- Yes
- No
Type and daily quantity
Caffeine Consumption
- Yes
- No
Type and daily quantity
Alcohol
- Yes
- No
Type and daily quantity
Marijuana
- Yes
- No
Type and daily quantity
Cocaine
- Yes
- No
Type and daily quantity
Spice
- Yes
- No
Type and daily quantity
Heroin
- Yes
- No
Type and daily quantity
Hallucinogens
- Yes
- No
Type and daily quantity
Methamphetamines
- Yes
- No
Type and daily quantity
Benzodiazepines
- Yes
- No
Type and daily quantity
Inhalants
- Yes
- No
Type and daily quantity
Ecstasy
- Yes
- No
Type and daily quantity
Other
- Yes
- No
Type and daily quantity
Do you exercise
- Yes
- No
List type and how often
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.
If known, please list previous diagnoses
Please list the locations you have receive Mental Health services (Type - ex Out-patient; Facility, Date and Reason)
Briefly describe your reasons for consultation today
How long has it been a problem for you?
Please list current symptoms.
Please provide additional information you feel is important to you.
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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Location & Hours

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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Latest News

Northland Counseling Center

April 6, 2017

Complete Continuum of Care

Northland Counseling Center, Inc.
Grand Rapids
Hibbing
International Falls
Kiesler Wellness Center
Aitkin
Healing Foundations Therapeutic Farm

Northland Recovery Center, Inc.
Grand Rapids, MN
International Falls, MN

Copyright © 2020 Northland Counseling Center.
All Rights Reserved.

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.