Medical and 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?
If Yes, Dates & Details:
Have you had any serious accidents/head injuries/seizure activity?
If Yes, Dates & Details:

  I have this now * I have had this in the past. Comments
I often feel like I am an outsider
Sexual problems/challenges
Worry that something is wrong with my body
Frequent arguments with the people I live with
I hear voices that others do not
Difficulty falling asleep or staying asleep
Sleeping too much
Change in appetite, weight loss, or weight gain
Frequent crying
Panic attacks or anxiety attacks
Thoughts/feelings of killing or hurting myself
Problems concentrating
Problems remembering things
Periods of daily sadness lasting more than two weeks
I startle easily
Can’t stop remembering upsetting past events
Difficulty controlling my temper
I physically hurt other people
I break things sometimes
I worry a lot
I feel tired almost every day