Pitts Davis Counseling Services

Client Name *

First

Last

How would you rate your current physical health? *

What was the date of your last medical examination? *

Doctor's Name *

First

Last

Doctor's or Healthcare Facility Address *

Address Line 1

Address Line 2

City

State

Zip Code

Do you have any current serious or chronic medical conditions? If yes, list details. *

Do you have any chronic pain, recurring body aches or soreness? Where is your body stress? *

Have you had any serious acidents/head injuries/seizure activity? If yes, please list dates and details. *

Please list all medications you are currently taking, along with dosages. *

List all important past illnesses, injuries, surgeries and/or hospitalizations. *

Do you smoke, and if so, how much? *

Do you drink alcohol, and if so, how much? *

Do you now have, or have you in the past had, a drug or alcohol problem? *

Do you have any history of treatment for substance abuse problems? *

Client Signature *

Today's Date *