PATIENT #009847021
Jan. 26th, 2022 09:19 amNAME: David Mills
SEX: (M) F Other(specify): _________
AGE: 31
RACE: (Caucasian/White) Am. Indian/Alaska Native Hispanic African/Black Asian Other: ________
D.O.B.: December 6, 1963
Partnerships: Single Married Divorced (Widowed)
Past Substance Abuse: Y (N)

SEX: (M) F Other(specify): _________
AGE: 31
RACE: (Caucasian/White) Am. Indian/Alaska Native Hispanic African/Black Asian Other: ________
D.O.B.: December 6, 1963
Please circle all concerns:Medications: Any medication(s) ever prescribed for these concerns? (Y) N
(Job)
Finances
Parenting / Child problems
(Violence / Physical abuse)
Divorce / Stepfamily
(Depression)
(Suicide thoughts / Actions / Wish to die)
(Worries / Anxiety / Panic attacks)
(Obsessions / Compulsions)
(Sleep problems / Tired)
Eating / Appetite / Weight / Food worries
Self-esteem
Withdrawn / Shy / Few Friends
(Concentration / Focus / Forgetfulness)
Relationship / Marriage issues
(Irritability / Temper / Anger)
(Impulsive)
Sexual abuse / Date rape
Alcohol / Drug use (self)
Alcohol / Drug use (other)
Relatives problems
(Death of a loved one / Other Losses)
Cutting / Self-injury to feel better
(Harm to others)
Health / Pain / Medications
(Legal problems)
(Hallucinations)
Sexual problems
Gay / Lesbian / Bi / Transgender issues
(Other) Refer to notes.
Partnerships: Single Married Divorced (Widowed)
Past Substance Abuse: Y (N)
