Substance Abuse Program Medical History Form
Personal Information
Full Name
Date of Birth
Phone Number
Address
Emergency Contact Name & Relationship
Emergency Contact Phone
Medical History
Have you ever been diagnosed with or treated for:
Diabetes
Hypertension
Heart Disease
Seizures
Asthma
HIV/AIDS
Other
If 'Other', please specify
List current medications (name, dosage, frequency):
Allergies (medications, foods, etc.):
History of hospitalizations or surgeries (please describe):
Mental Health History
Have you ever been diagnosed with or treated for mental health conditions?
Depression
Anxiety
Bipolar Disorder
Schizophrenia
PTSD
Other
If 'Other', please specify
Have you received counseling or psychiatric care?
Yes
No
Substance Use History
Substances used (alcohol, tobacco, drugs, etc.):
Age at first use:
Frequency and amount used:
Date/Time of last use:
Have you had prior substance abuse treatment?
Yes
No
If yes, where and when?