Clinical Assessment Form

Bring together a patient's medical, family, and personal history in a single intake session to support the initial clinical evaluation.

Use this template

Name

Nombre

Apellido

Date

Date of Birth

Name of Spouse

Nombre

Apellido

Phone Number

Alternative Phone Number (if any)

Home Address

Dirección

Ciudad

Estado / Provincia

Código postal

Phone Number

Name of Referrer

Nombre

Apellido

Chief Concern

Do you currently have any other known medical problems?

Yes No

Please explain

Have you ever been treated for any of the following?

Please explain

Have you previously seen a therapist or psychiatrist?

Yes No

Please explain

Have you ever been hospitalized for medical or mental illness?

Yes No

Please explain

Are you currently taking any prescription medications?

Yes No

Please indicate the names and dosage

Have you previously taken any prescription medications?

Yes No

Please indicate (names, dosage, when)

Do you drink alcohol or use recreational drugs?

Yes No

Please indicate the kind and frequency

Name Of Your Primary Care Physician

Nombre

Apellido

Name Of Psychiatrist/Psychologist (if applicable)

Nombre

Apellido

Date of Last Complete Physical Examination

What type of food do you regularly eat?

How frequent do you exercise and how long?

Were you adopted?

Yes No

Number of Years Your Parents Married

Are They Divorced?

Yes No

How Old Were You When They Divorced?

Have had family difficulties during growing up?

Are you living in with a partner?

Yes No

Are there any concerns about your current relationship that you would like to discuss?

Please describe your current custody & visitation schedule (if any) and the status of your communication:

Please describe briefly your social relationships with family, colleagues, and friends

Are you Currently Working and/or Studying?

Working Studying Both Neither

Please describe your situation academically and/or professionally

Please indicate/describe what activities interests you

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Clinical Assessment Form

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