Form #1 (rev 6/99) Medical/Psycho/Social History
Client Name________________________________________ Date _____________________
Medical History
====================================================================
Self Father
Mother Spouse
Child# 1 Child#2
Child# 3
Age
-----------------------------------------------------------------------------------------------------------------------
High BP/
Blackouts
-----------------------------------------------------------------------------------------------------------------------
Nervous/
mental
health
problems
------------------------------------------------------------------------------------------------------------------------
Allergies
------------------------------------------------------------------------------------------------------------------------
Cause of
Death
------------------------------------------------------------------------------------------------------------------------
Other/
Concerns
====================================================================
Date of Last Physical
Name of MD
====================================================================
Psycho/Social History
Comment Yes / No
Comment
Yes / No
====================================================================
Family Hx (AODA/MH
Support
Abuse, Other)
Network
--------------------------------------------------------------
------------------------------------------------------
Developmental Hx(Sig)
Closest
--------------------------------------------------------------
Friend
Sig Relationships
------------------------------------------------------
--------------------------------------------------------------
Past
Sig Life Events
Treatment
--------------------------------------------------------------
------------------------------------------------------
Drug Uses
Treatment
--------------------------------------------------------------
Issues
Family Pattern AODA
------------------------------------------------------
--------------------------------------------------------------
Hobbies/
Hospitalizations
Pastime
--------------------------------------------------------------
------------------------------------------------------
Briefly summarize
Family of Origin, Social and Psychological hx;
Use back of form to
continue or provide Geno gram.