PATIENT HISTORY

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PATIENT HISTORY Powered By Docstoc
					                                        KAREN D. NICHOLS, PH.D.
                                      11808 Northup Way, Suite W-150
                                            Bellevue, WA 98005
                                              (425) 889-1240


                                             CLIENT HISTORY


Name: __________________________________________

Place of Birth: _____________________________________

Age: _______


Family of Origin:             AGE            OCCUPATION                    CITY OF RESIDENCE

Mother                       ______     ______________________          ______________________

Father                       ______     ______________________          ______________________

Step-Mother         ______      ______________________         ______________________

Step-Father                  ______     ______________________          ______________________

Brothers/Sisters             ______     ______________________          ______________________
(specify which)
                             ______     ______________________          ______________________

                             ______     ______________________          ______________________


Were your parents separated or divorced? ___________________

How old were you at the time? ________

History of mental health problems in your family? _______________________________________
(anxiety, depression, phobias, suicide attempts)
____________________________________________________________________________

Has anyone in your family had counseling? ___________________________________________

History of alcohol abuse in your family? ______________________________________________


Education:          Highest Grade Completed: ___________       Year Completed: ________________

Vocational History:    Please list most recent jobs and approximate dates at your jobs.

_____________________________________________________________________________

Any involvement with the law? _____________________________________________________
Marital History:

Years married: ___________________       Spouse Name: __________________

Children’s Names: _________________________      Age: ________

                   _________________________     Age: ________

                   _________________________     Age: ________

                   _________________________     Age: ________

Divorce or Separations? ______________   Year: ________ Reason: _______________________

Other marriages, divorces, offspring: __________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Who lives in your current household?_________________________________________________


Have you had an alcohol problem? ______ Years duration: _______ Dates: __________________

Have you had a drug problem? ________    Years duration: _______ Dates: __________________


History of medical illnesses or surgeries and dates: _______________________________________

______________________________________________________________________________

______________________________________________________________________________

History of previous counseling, list dates: ______________________________________________

______________________________________________________________________________

______________________________________________________________________________

Reason for current visit: ___________________________________________________________

______________________________________________________________________________

______________________________________________________________________________



        _________________________________________                 _______________________
        Client Signature                                          Date

				
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