Client Health Questionnaire
Name:_________________________________Age:_____Height______Weight:_____
Medical Care:
Are you currently receiving medical care or treatment? ___yes ___no
Most recent physician/clinic________________________________________
Physician/clinic’s phone & fax number:_____________/____________
Approximate date of last exam________
List any physical problems for which you are now, or were under a doctor’s
care (include any surgeries within the last two years).
_________________________________________________________________
Prescription Medications:
Are you currently taking any medications for physical or mental health
reasons? ___yes ___no
Please list all prescription and non-prescription drugs used currently or
during the last 6 months including birth control pills.
Name
Dosage
Prescriber
Current
_______________________ ____________ ________________
__yes__no
Allergies:
List known allergies (including medications, foods,or other) and the type of reaction you experence:
_________________________________________________________________
Hospital History:
Have you been hospitalized recently?___Yes___No
Have you ever been hospitalized for mental health reasons?___Yes___No