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Medical Screening Form

Perform with Bio-Psycho-Social Assessment
(Form Physician Approved- Required by Substance Abuse Standards, JAHCO & CARF)

Name*

First
Last
Email
Client #
Current Medical Conditions
Have you Ever Had: (Check all that apply to you)
Major Illnesses*
- Yes
- No
If yes please fill in description box that appears.
Describe*
Severe fatigue after little activity*
- Yes
- No
If yes please fill in description box that appears.
Describe*
Feeling tired all the time*
- Yes
- No
If yes please fill in description box that appears.
Describe*
Unusual swelling or lumps*
- Yes
- No
If yes please fill in description box that appears.
Describe*
Heart problems in self or family*
- Yes
- No
If yes please fill in description box that appears.
Describe*
Blurred vision or difficulty seeing*
- Yes
- No
If yes please fill in description box that appears.
Describe*
Shortness of breath with exercise*
- Yes
- No
If yes please fill in description box that appears.
Describe*
Buzzing or ringing in your ears*
- Yes
- No
If yes please fill in description box that appears.
Describe*
Swollen feet or ankles*
- Yes
- No
If yes please fill in description box that appears.
Describe*
Frequent coughs or colds*
- Yes
- No
If yes please fill in description box that appears.
Describe*
Severe headaches*
- Yes
- No
If yes please fill in description box that appears.
Describe*
Problems with your sleep or rest*
- Yes
- No
If yes please fill in description box that appears.
Describe*
Bleeding gums or teeth problems*
- Yes
- No
If yes please fill in description box that appears.
Describe*
Aching joints or muscles*
- Yes
- No
If yes please fill in description box that appears.
Describe*
Constipation or diarrhea*
- Yes
- No
If yes please fill in description box that appears.
Describe*
Unusual thirst or hunger*
- Yes
- No
If yes please fill in description box that appears.
Describe*
Major injuries / surgeries*
- Yes
- No
If yes please fill in description box that appears.
Describe*
Recent changes in your weight*
- Yes
- No
If yes please fill in description box that appears.
Describe*
Allergies (foods, drugs, or others)*
- Yes
- No
If yes please fill in description box that appears.
Describe*
Any problem with urination*
- Yes
- No
If yes please fill in description box that appears.
Describe*
Blood in your stool or urine*
- Yes
- No
If yes please fill in description box that appears.
Describe*
Appetite / ability to eat changes*
- Yes
- No
If yes please fill in description box that appears.
Describe*
Diabetes*
- Yes
- No
If yes please fill in description box that appears.
Describe*
Date of last physical exam
Doctors Name:
Date of last dental exam
Dentists Name:
Date of last vision exam
Eye Doctors Name:
For Females Only – Do you or have you had: (check all that apply to you)
Any unusual vaginal discharge?*
- Yes
- No
Describe*
Regular periods?*
- Yes
- No
Excessive menstrual bleeding?*
- Yes
- No
Describe*
Do you use birth control*
- Yes
- No
Type:
Currently on hormone therapy?*
- Yes
- No
When was your last PAP smear
When was your last pregnancy?
Infectious Disease Form:
Client Signature
Date
Counselor Signature
Date
Email

This field is for validation purposes and should be left unchanged.

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Set Free Alaska

Office - 907-373-4732

Fax - 907-746-4749

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Medical Screening Form

Medical Screening Form

Have you Ever Had: (Check all that apply to you)

For Females Only – Do you or have you had: (check all that apply to you)