Address:(Street, City, State, Zip)

County: Home Phone #:()- 2nd Phone #:()- Sex: Male Female

Social Security #:--Date of Birth: // Age:

Who referred you to us?

Race: White Black/African American American Indian Asian Hispanic/Latino Other

Marital Status: Married Divorced Separated Single

Present Employer: Work Phone: ()- How Long:Year(s) Month(s)

Work Address:(Street, City, State, Zip)

Income: $.00 Yearly MonthlyNumber of Children Living With You:Ages:

Number of Children Not Living With You:Ages:

Emergency Contact: Relationship:

Primary Phone Number:()- Secondary Phone #:()-

Address:(Street, City, State, Zip)

Family Physician: Physician Phone #:()-

Address:(Street, City, State, Zip)

Have you ever been treated for alcohol and/or substance abuse service before? YES No

If Yes, please answer the following!!!!! Give Names and Dates(to the best of your knowledge of Treatment Facilities.)
1.
2.
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4.
5.
6.

Health and Drug History

Father: Age() If Living, How is Health? () (If Not Living)Age at Death? () If Deceased, Cause? ()

Mother:Age() If Living, How is Health? () (If Not Living)Age at Death? () If Deceased, Cause? ()

Sibling 1:Age() If Living, How is Health? () (If Not Living)Age at Death? () If Deceased, Cause? ()

Sibling 2:Age() If Living, How is Health? () (If Not Living)Age at Death? () If Deceased, Cause? ()

Sibling 3:Age() If Living, How is Health? () (If Not Living)Age at Death? () If Deceased, Cause? ()

Sibling 4:Age() If Living, How is Health? () (If Not Living)Age at Death? () If Deceased, Cause? ()

Spouse:Age() If Living, How is Health? () (If Not Living)Age at Death? () If Deceased, Cause? ()

Children 1:Age() If Living, How is Health? () (If Not Living)Age at Death? () If Deceased, Cause? ()

Children 2:Age() If Living, How is Health? () (If Not Living)Age at Death? () If Deceased, Cause? ()

Children 3:Age() If Living, How is Health? () (If Not Living)Age at Death? () If Deceased, Cause? ()

Children 4:Age() If Living, How is Health? () (If Not Living)Age at Death? () If Deceased, Cause? ()

Have you or any relative had(Please check one-If yes, briefly explain)
1. Cancer : No Yes (Please tell who:)
2. Tubercolosis : No Yes (Please tell who:)
3. Diabetes : No Yes (Please tell who:)
4. Heart Trouble : No Yes (Please tell who:)
5. Stroke : No Yes (Please tell who:)
6. High Blood Presure : No Yes (Please tell who:)
7. Epilepsy : No Yes (Please tell who:)
8. Mental Health : No Yes (Please tell who:)

Personal History(Please check one-If yes, biefly explain)
Illnesses
1. Measles : No Yes (Explain:)
2. German Measles : No Yes (Explain:)
3. Mumps : No Yes (Explain:)
4. Diphtheria : No Yes (Explain:)
5. Pnuemonia : No Yes (Explain:)
6. Rheumatic Fever/Heart Disease : No Yes (Explain:)
7. Arthritis/Rheumatism: No Yes (Explain:)
8. Bone/Joint Disease : No Yes (Explain:)
9. Kidney Disease: No Yes (Explain:)
10. Polio : No Yes (Explain:)
12. Meningitis : No Yes (Explain:)
13. Gonorrhea : No Yes (Explain:)
13. Gastrointestinal : No Yes (Explain:)
14. Stomach Problems : No Yes (Explain:)
15. Syphilis : No Yes (Explain:)
16. Anemia : No Yes (Explain:)
17. Jaundice : No Yes (Explain:)
18. Migraine Headaches : No Yes (Explain:)
19. Hay Fever/Asthma : No Yes (Explain:)
20. Food/Chemical/Drug Poisoning : No Yes (Explain:)
21. Skin Problems : No Yes (Explain:)
22. Frequent Infections : No Yes (Explain:)
23. Frequent Colds/Sore Throats : No Yes (Explain:)
24. Thyroid Disease : No Yes (Explain:)
25. Other : No Yes (Explain:)

Pregnancies:
How Many? (Total)(Still Births)(Premature Births)(Spontaneous Abortions)(Surgical Abortions)
Other Pregnancy Complications:

Injuries:
(Broken Bones): No Yes (Explain:)
(Concussion/Head Injury): No Yes (Explain:)
(Ever been knocked unconscious?): No Yes (Explain:)

Menstrual History:
Date of First Period://(Regular): No Yes(Last Period:) //(Flow:)(Days:)
Date of Menopause onset:

Do you have any Allergies(including medicines)?No Yes(If you have any allegies please list them below)
1.
2.
3.
4.
5.
6.
7.
8.

1) List below any prescribed medication that you are on or should be taking.
1. Amount:Physician:Phone #:)-Do you have enough to Last through TX? No Yes
2. Amount:Physician:Phone #:)-Do you have enough to Last through TX? No Yes
3. Amount:Physician:Phone #:)-Do you have enough to Last through TX? No Yes
4. Amount:Physician:Phone #:)-Do you have enough to Last through TX? No Yes
5. Amount:Physician:Phone #:)-Do you have enough to Last through TX? No Yes
6. Amount:Physician:Phone #:)-Do you have enough to Last through TX? No Yes
7. Amount:Physician:Phone #:)-Do you have enough to Last through TX? No Yes
8. Amount:Physician:Phone #:)-Do you have enough to Last through TX? No Yes
9. Amount:Physician:Phone #:)-Do you have enough to Last through TX? No Yes

2) Rate your general health!Poor
GoodExcellentDescribe:

3) Are you currently being treated for a medical and/or surgical problem(s)? No Yes
Describe:

4) Do you currently use tobacco products?No Yes
If yes, Describe type/amount:

5) Have you had any recent change in appetite?No Yes
Describe:
Weight: (Now): (6 Months Ago) (Max.)

6.) Have you had any recent change in Sleep Paterns?No Yes
Describe:

7.) Have you ever attempted to harm yourself?No Yes
Describe:

8.) Are you currently having thoughts of self harm?No Yes
Describe:

9.) Have you ever been violent or hurt anyone else in the past?No Yes
Describe:

10.) Are you currently having thoughts of hurting anyone else?No Yes
Describe: