Gelbloom

Home Appointments Reports Admin

Client Details

Client Name: Jamie Jones	CIN: XV99999F	Case Number:0000999999-01-01	Case Status: SI
SSN: 999-99-9999	DOB: 01/01/2015	Job Center: 999

Client Info RA ADLs Employment Education/Training Medical Hist Mental Health Hist Substance Use Hist Family Hist Functional Limits Domestic Violence Strengths/Barriers

Medical Health History

In addition to the medical issues identified previously, describe what other medical conditions prevent the client from working.

Diagnosis or Conditions or Symptoms	Current / History	Treated / Untreated
	--SELECT-- Current History	--SELECT-- Treated Untreated
Lower back pain

Treating Physician

Name	Specialty                         --SELECT-- Cardiology Orthopedic Physiatry Psychiatry
Address	Treatment Type              --SELECT-- Medications Surgery Therapy
City	Compliance w/treatment  --SELECT-- Yes No
Ph. Number	Reasons for non-compliance

Pain Assessment

--SELECT-- Yes No

Location of Pain           

Description of Pain  
Severity of Pain      

Prescribed Medications   --SELECT-- Yes No

Medication Name	Dosage

Hospitalization                 Yes No --SELECT--

Describe  

HIV Consent Form           Signed Not Signed --SELECT--

HIV Status Positive Negative Doesn't know Refuses to answer --SELECT--

HIV Medical Treatment  --SELECT-- Yes No

AIDS  --SELECT-- Yes No

       

AIDS Yes No --SELECT--

If receiving medical treatment, explain

If HIV status is not known, ask the following questions:

History of unprotected sex or IV Yes No --SELECT--
Open to testing Yes No --SELECT--

Family History / Genetic Diseases

If Other, Specify

Allergies

If Other, Specify

Mental Health History

Mental Health History

In addition to the mental issues identified previously, describe what other mental conditions prevent the client from working.
Ask if the client ever thought or tried to hurt or kill themselves                --SELECT-- Yes No

Give details including dates (if known)

Ask if the client currently has thoughts about  hurting/killing themselves --SELECT-- Yes No

Give details including dates (if known)

Ask if the client ever thought about or tried to hurt/kill others                   --SELECT-- Yes No

Give details including dates (if known)

Ask if the client currently has thoughts about hurting/killing others          --SELECT-- Yes No

Give details including dates (if known)

Ask if the client reports hearing voices, seeing things, has bizarre          --SELECT-- Yes No
beliefs or exhibits any other unusual behaviors        

Give details including dates (if known)