PATIENT #009847021

NAME: 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

Please circle all concerns:

(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Withdrawn / Shy / Few Friends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.

Medications: Any medication(s) ever prescribed for these concerns?  (Y)  N

Partnerships: Single    Married     Divorced     (Widowed)

Past Substance Abuse:  Y  (N)