CLINTON COUNSELING CENTER STUDENT SOCIAL MEDICAL QUESTIONNAIRE
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1 CLINTON COUNSELING CENTER STUDENT SOCIAL MEDICAL QUESTIONNAIRE Please respond to ALL questions/information. There are multiple two sided pages. Check to be sure you have completed them all. Provide the requested information to the best of your ability. Identifying Data: Name: Birth Date: / / Age: Sex Address: (Street) (City) (State) (Zip Code) Phone Numbers: Home: ( )- - Emergency Contact: Name #( )- - Why are you coming in for counseling at this time: How long has this situation been a problem or concern for you? How did you hear about Clinton Counseling Center? Have you ever been to Clinton Counseling Center before for any reason? [ ] Yes [ ] No [ ] Unsure If so, when? Race: [ ] Caucasian [ ] Black [ ] Hispanic [ ] Asian [ ] Native American [ ] Other: Is there ANY CHANCE that you are currently pregnant? [ ] Yes [ ] No [ ] Unsure [ ] N/A Family/Cultural Information: Who is raising you? # in your family: # of Brothers: Parents Current Marital Status: # of Sisters: If parent (s) deceased, how old were you at the time? If parents divorced, how old were you at the time: Who raised you after the divorce? Who do you live with? Describe your relationship with: Your father: Your mother: Your brothers and sisters: 1 Can you talk to your mom, dad, brothers, or sisters about your problems or concerns? [ ] Yes [ ] No
2 If no, who do you talk to when you have a problem? Are there consequences set by your parents when you misbehave or disobey house rules? [ ] Yes [ ] No How do you feel about this? Educational History: Highest level of achievement:[ ] Still in school: What grade are you in: What school do you go to? [ ] High School Graduate [ ] GED Completion [ ] Some College (Credits: ) [ ] Dropped out of school - Reason: What was highest grade completed? School performance: [ ] A-B Student [ ] B-C Student [ ] C-D Student [ ] Failing Have you ever been suspended from school? [ ] Yes [ ] No Have you ever been expelled from school? [ ] Yes [ ] No Have you ever repeated a grade? [ ] Yes [ ] No Have you ever been enrolled in special education classes? [ ] Yes [ ] No Do you have trouble concentrating, understanding, or remembering? [ ] Yes [ ] No Do you like school? [ ] Yes [ ] No If No, Why not? What would make school better for you? Religious/Spiritual Background: Do you practice your religion? [ ] Regularly [ ] Irregularly [ ] Never What is you current religious preference/affiliation: Do you believe in God/Higher Power? [ ] Yes [ ] No Vocational Background: Are you currently employed? [ ] Yes [ ] No If employed, length of employment at present job: If employed, how many hours a week do you work? Job Title/Position: Are satisfied with your work? Job History: Type Work Length of employment Reason for leaving Degree of Satisfaction 2 2
3 If you experience any problems with employment state them: Sexual Background: Are you sexually active? [ ] Yes [ ] No [ ] Unsure If so, what type of birth control have you been using? I consider myself to be: [ ] Heterosexual [ ] Homosexual [ ] Bisexual [ ] I am uncertain about my sexuality Have you ever been: [ ] Sexually Abused [ ] Physically Abused [ ] Emotionally Abused By whom? Age when abused: Duration of Abuse: Did you receive any kind of help after being abused? If so, what kind and by whom? Social Background: With whom do you spend MOST of your free time: [ ] Family [ ] Friends [ ] Acquaintances [ ] Alone How often do you see your friends/acquaintances: [ ] Daily [ ] Frequently [ ] Occasionally [ ] Rarely [ ] Never Do you have a best friend outside of your family? How often do you see that person? How many close friends do you have? How many acquaintances do you have? What do you and your friends/acquaintances typically do together? Does your mom/dad/care giver like your friends? Have you recently changed your circle of friends/best friend? [ ] Yes [ ] No If so, what were the circumstances? Do you ever feel as if you do not belong? [ ] Yes [ ] No Do you have trouble making or keeping friends? [ ] Yes [ ] No Do you have a curfew? [ ] Yes [ ] No Have you had problems following house rules? [ ] Yes [ ] No Do you have chores? [ ] Yes [ ] No If so, what chores are you responsible for? Have you ever run away from home? [ ] Yes [ ] No 3
4 Is there anything that you would like to see change at home that would make your life better? [ ] Yes [ ] No If so, what things would you like to see change? Leisure Time/Interests: List any hobbies, interests, or school activities: Do you participate in your hobbies etc? [ ] Regularly [ ] Sometimes [ ] Irregularly [ ] Rarely [ ] Never Has your use of leisure time changed in the past year? [ ] Yes [ ] No If yes to above question, describe changes: Describe your typical day: Legal Status: I am currently:[ ] On probation [ ] Awaiting charges [ ] Awaiting trial/sentence [ ] No police involvement How many times have you been arrested or ticketed in the last 5 years? In the last 6 months? Charges Date Outcome Alcohol/Drug Related [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No Have you ever been in the Youth Home before? [ ] Yes [ ] No Medical/Health History: Do you have a routine health care provider (non-emergency room)? [ ] Yes [ ] No If so, please provide the doctor/practice name and city where the office is located: Have you had a physical exam in the last year? [ ] Yes [ ] No Do you have any current medical complaints or recurring physical symptoms/pain that you are not receiving medical attention for? [ ] Yes [ ] No Do you have any current physical impairments or disabilities that you are not receiving medical attention for? [ ] Yes [ ] No 4
5 Do you have health insurance? [ ] Yes [ ] No Have you ever talked with a therapist or counselor before? [ ] Yes [ ] No If so - for what reason(s): Problems Year/Age Outcome Do you presently feel suicidal: [ ] Yes [ ] No Do you presently feel homicidal: [ ] Yes [ ] No Have you ever attempted to or had serious thoughts of suicide or of hurting other people? [ ] Yes [ ] No If so, when did this happen and what was the outcome? Any current medications that you take for any reason: Type/Name/Dosage Why do you take it? Who prescribes this for you? For the last month have you been: [ ] Sleeping too much [ ] Not sleeping enough [ ] Getting the right amount of sleep Do you currently experience: [ ] Trouble getting to sleep [ ] Frequent waking [ ] Early rising [ ] None of these problems Have your sleeping habits changed in the last 6 months? [ ] Yes [ ] No If so, how? For the last month have you been: [ ] Under eating [ ] Starving myself [ ] Over eating [ ] Eating with no trouble You eat: [ ] A well balanced diet [ ] Junk food [ ] Fast foods [ ] Whatever is available, without thought Have your eating habits changed in the last 6 months? [ ] Yes [ ] No If so, how? Alcohol/Drug Use: Have you used ANY alcohol or drugs in the last 30 days that were not prescribed for you? [ ] Yes [ ] No Have you used any drugs by injection in the last 10 years? [ ] Yes [ ] No If so, when was the last time and which drug(s) were you injecting? Do you smoke cigarettes? [ ] Yes [ ] No 5
6 When was the last time you used ANY drugs or alcohol? Do you live with any people who use alcohol or other drugs? [ ] Yes [ ] No If so, what concerns (if any) do you have about this? Do you live in an environment/neighborhood where alcohol or other drugs are easily available to you? [ ] Yes [ ] No If so, what concerns (if any) do you have about this? What kinds of problems (if any) has alcohol or other drug use caused in your life to date? Please place a check mark in the box of any substance you have used in the last 12 months. Please mark the number of days you have used each drug in the last 30 days in the space following each drug: Used? # of days in last 30 Used? # of days in last 30 Used? # of days in last 30 [ ] Alcohol [ ] Opiates/Heroin [ ] Cocaine [ ] Crack [ ] Sedatives [ ] Barbiturates [ ] Amphetamines [ ] Marijuana [ ] Hallucinogens [ ] Steroids [ ] Inhalants [ ] Other What is your preferred substance? Do you use substances while: [ ] Alone [ ] With others [ ] Both Additional Information: Do you have anything to add to this information: (Signature of Person Providing Information) (Relationship to Patient) I have reviewed this questionnaire with the patient/client: (Therapist Signature and Credentials) (Date) (Date) Revision: 11/99 SLM 6
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