Read GENERALCounselingIntakeForm_v111007.xls text version

Complete The Front AND Back of Form. Please Answer Each Question by Filling In The Bubbles.

COUNSELING INTAKE FORM

INITIAL LAST NAME

Today's Date: ______/______/______

FIRST NAME ADDRESS CITY, STATE, ZIP PHONE NUMBER SOCIAL SECURITY # MEDICATION ALLERGIES HEIGHT _____feet _____ inches

No

HAVE YOU BEEN HERE BEFORE? No INFO CHANGED SINCE YOUR LAST VISIT?

Yes No

Yes Other

RACE GENDER

Black Male

Haitian

White

Hispanic

Female

Transgender

DATE OF BIRTH ______/______/___________

Yes (please describe) _______________________________________

COUNTRY OF BIRTH

USA

Other_____________ English Spanish Creole

WEIGHT ___________ pounds (if not sure, write in your best guess)

PREFERRED LANGUAGE

K no w D on 't

SECTION 1: PERSONAL & FAMILY HEALTH HISTORY

(Family is your immediate blood relatives - mother, father, sisters, brothers)

1. Have you been seen by a doctor in the past 12 months? 2. Has a doctor ever told you that you have high blood pressure? 3. Has a doctor ever told you that you have high cholesterol? 4. Has a doctor ever told you that you have blood sugar problems? 5. Do you use tobacco (chewed or smoked)? 6. Do you use alcohol and/or drugs until you get drunk/high/wasted? 7. Any male family diagnosed with heart disease before the age of 50? 8. Any female family diagnosed with heart disease before the age of 60? 9. Does any family member have high blood pressure? 10. Does any family member have high cholesterol? 11. Does any family member have diabetes (blood sugar problems)?

e M Pas on t th N ev er

For what reason? When? When? When? How many/How often? How often? Which ones? Which ones? Which ones? Which ones? Which ones?

to 3 on th A s go

If

YE pl S ea an se sw er

Ye s

N o

Father Mother Father Father Father

Brother Sister Mother Mother Mother Sister Sister Sister

D on R 't ec al l

Brother Brother Brother

C om m en t

SECTION 2: WHEN WAS THE LAST TIME YOU: 1. Got TESTED for HIV (the virus that causes AIDS) 2. Got TESTED for Hepatitis A, B, and C 3. Got TESTED for STDs 4. Got DIAGNOSED with an STD 5. Got VACCINATED for Hepatitis A and/or Hepatitis B 6. Were Treated With a Blood Transfusion or Blood Products 7. Shared Needles, Syringes, or "Works" to Inject Drugs (even once) 8. Traded Sex for Drugs, Money and/or Gifts 9. Were in a Detention Center, Jail, or Prison (even one day) 10. Had Injections, Surgical or Dental Procedures Outside of the U.S. 11. Were a Victim of a Sexual Assault / Rape

In

to M 12 on th A s go M or e 12 Th M an on A ths go

Th

1

M

4

Th Pa e s M t on th 1 to M 3 on th A s go 4 to M 12 on th A s go M or e 12 Th M an on A ths go

N ev er

D on K 't no w

SECTION 3: WHEN WAS THE LAST TIME YOU HAD SEX WITH: 1. Males 2. Females 3. Transgendered Persons (he/she or she/he) 4. A Man Who Has Sex With Other Men 5. A Person Who Injects or Injected Drugs 6. A Person Who Trades Sex for Drugs, Money and/or Gifts 7. A Person Who You Don't Know (Anonymous Sex) 8. A Person Whose Hepatitis, STD, or HIV Status is Unknown 9. A Person Who You Know Has HIV

D on Th 't H is av Ty e p Se e o x f

M or 20 e T Pa han rt ne rs

SECTION 4: HOW MANY DIFFERENT SEX PARTNERS HAVE YOU HAD IN THE PAST 3 MONTHS FOR: 1. Oral Sex (YOUR mouth on someone's penis/vagina/anus) 2. Oral Sex (their mouth on YOUR penis/vagina/anus) 3. Vaginal Sex (penis in vagina) 4. Anal Sex (YOUR penis in someone's anus) 5. Anal Sex (their penis in YOUR anus)

2 to Pa 5 rt ne rs

6 to Pa 20 rt ne rs

Pa r

Pa r

D on Th 't H is av Ty e p Se e o x f

es

SECTION 5: HOW OFTEN DO YOU USE LATEX CONDOMS? 1. For Oral Sex 2. For Anal Sex 3. For Vaginal Sex

SECTION 6: SEX PARTNERS 1. How Many Different Sex Partners Have You Had in the Past Year?

2. When Was Your Last Unprotected Vaginal, Anal or Oral Sex? 3. How Many Different Needle-Sharing Partners Have You Had in the Past Year?

: wer Ans : wer Ans : wer Ans

SECTION 7: FOR WOMEN ONLY 1. How Many Times Have You Been Pregnant? 2. Are You Pregnant Right Now? (If YES, Are You In Prenatal Care?) 3. What Type Of Birth Control Are You Currently Using? 4. When Was Your Last Female Exam (Pap Test)? 5. Are You Interested in the Cervical Cancer Vaccine?

: wer Ans : wer Ans : wer Ans : wer Ans : wer Ans

C om m en

s

et im

lw

So m

A

N

ev er

ay

t

C om

0

1

m en t

tn er s

tn er

C om

In

m en

t

Information

GENERALCounselingIntakeForm_v111007.xls

2 pages

Report File (DMCA)

Our content is added by our users. We aim to remove reported files within 1 working day. Please use this link to notify us:

Report this file as copyright or inappropriate

540940

You might also be interested in

BETA
DRiG - englisch
1
301GenesisWrkAW6 (WP)
Papers of Vincent Price [finding aid]. Library of Congress. [PDF rendered 2006-05-05.153155.52]