Medical Health History Medical Health History Name Date Date of your most recent physical examination Psychiatrist – (If applicable): Please sign release for Elisa Elkin-Cleary, LICSW to communicate with your psychiatrist for treatment considerations, and in an effort to provide consistency and quality care. Current medications, dosage, start date Allergies Primary reason(s) for seeking help at this time How long have you had these problems and/or symptoms? What have you tried in attempting to address this issue? Do you have any serious or chronic medical conditions? Yes No If yes, dates & details Have you had any serious accidents/head injuries/seizure activity? Yes No If yes, dates & details I often feel like I am an outsider Have now Had in past Sexual problems/challenges Have now Had in past Worry that something is wrong with my body Have now Had in past Frequent arguments with the people I live with Have now Had in past I hear voices that others do not Have now Had in past Difficulty falling asleep or staying asleep Have now Had in past Sleeping too much Have now Had in past Change in appetite, weight loss, or weight gain Have now Had in past Frequent crying Have now Had in past Panic attacks or anxiety attacks Have now Had in past Thoughts/feelings of killing or hurting myself Have now Had in past Problems concentrating Have now Had in past Problems remembering things Have now Had in past Periods of daily sadness lasting more than two weeks Have now Had in past I startle easily Have now Had in past Can’t stop remembering upsetting past events Have now Had in past Difficulty controlling my temper Have now Had in past I physically hurt other people Have now Had in past I break things sometimes Have now Had in past I worry a lot Have now Had in past I feel tired almost every day Have now Had in past reCAPTCHA If you are human, leave this field blank. Submit Δ