UNC Hospitals
Alcohol & Substance Abuse Program
Medical History Self-Questionnaire
Name:
Date:
Medical Record #:
Date of Birth:
Family Physician:
Date of Last Physical Exam:
A) Nutritional Screening
1. Normal weight:
2. Lost or gained weight recently: ______
3. Weight loss/gain associated with drug use: ______
4. Weight loss/gain associated with medical illness: ______
5. Past weight loss/gain: ______
6. Meals per day:
7. Supplemented vitamins for poor eating habits: ______
When:
Daily multi-vitamin: ______
B) Symptom Checklist
- __ Sleep problems
- __ Change in appetite
- __ Mood swings
- __ Crying spells
- __ Chest pains
- __ Anxiety attacks
- __ Dizziness
- __ Headaches
- __ Weight changes
- __ Breathing problems
- __ Tremors
- __ Lack of energy
- __ Fatigue
- __ Irritability
- __ Racing thoughts
- __ Hearing voices
- __ Unusual thoughts
- __ Nightmares
- __ Seizures
- __ Problems with sexual function
- __ Fainting spells
- __ Unusual fears
- __ Phobias
- __ Bad dreams
- __ Too much energy
- __ Inability to concentrate
- __ Palpitations
- __ Uncontrollable movements
- __ Paranoid thoughts
- __ Nausea
- __ Vomiting
- __ Eating problems
- __ Bulimia
- __ Anorexia
- __ Suicidal thoughts
- __ Problems dressing, grooming, or bathing
- __ Memory problems
- __ Loss of concentration
- __ Change in sexual desire
- __ Blackouts
- __ Excessive worry
- __ Feeding yourself
- __ Frequent diarrhea or constipation
- __ Difficulty urinating
- __ Thoughts of harming yourself
- __ Thoughts of harming other people
C) Medical Symptoms
| Condition | Yes/No |
|---|---|
| Asthma | __ |
| Seizures | __ |
| Emphysema | __ |
| Diabetes | __ |
| Heart Disease | __ |
| Ulcers | __ |
| Cancer | __ |
| Anemia | __ |
| Tuberculosis | __ |
| Kidney Problems | __ |
| Fainting/Dizziness | __ |
| Pancreatitis | __ |
| Rheumatic Fever | __ |
| Hepatitis (Type A, B, or C) | __ |
| Glaucoma | __ |
| Venereal Disease | __ |
| High Blood Pressure | __ |
| Arthritis | __ |
| Frequent Headaches | __ |
| Sinusitis | __ |
| PMS | __ |
| Back Problems/Injury | __ |
| Jaundice | __ |
| Swelling of Extremities | __ |
| Skin Problems | __ |
| Cirrhosis | __ |
| Liver Disease | __ |
| Abnormal Liver Tests | __ |
Other conditions:
Currently taking medications: ______
If yes, list:
Hospitalizations or Surgeries
| Date | Reason | Where |
|---|---|---|
Allergies
Foods:
Medications:
Other:
D) Life Experiences (Past Year)
- __ Death of spouse
- __ Divorce
- __ Marital separation
- __ Detention in jail
- __ Death of close family member
- __ Major personal injury or illness
- __ Marriage
- __ Being fired at work
- __ Marital reconciliation
- __ Retirement from work
- __ Major change in health or behavior of family member
- __ Pregnancy
- __ Sexual difficulties
- __ Gaining new member of family
- __ Major financial change
- __ Death of close friend
- __ Change in line of work
- __ Change in number of arguments with spouse
- __ Major change in job responsibility
- __ Child leaving home
- __ Trouble with in-laws
- __ Outstanding personal achievement
- __ Beginning or ending formal education
- __ Major change in living conditions
- __ Changes in personal habits
- __ Trouble with boss
- __ Major change in working hours or conditions
- __ Change in residence
- __ Change to a new school
- __ Change in amount or type of recreation
- __ Major change in group activities
- __ Major change in social activities
- __ Major change in sleeping habits
- __ Major change in family gatherings
- __ Major change in eating habits
E) Smoking
Do you smoke cigarettes? ______
If yes, # of cigarettes per day:
Smoking cessation info/referral:
F) Current Use
Use alcohol: ______
Other mood/altering drugs: ______
Alcohol frequency:
Daily drinks: Weekly drinks:
Stopped for DUI:
Complaints about amount you drink:
Consider alcohol a problem:
First alcohol use:
Last time drunk:
Last alcoholic beverage:
Drug use (number of times):
Marijuana: ______
Heroin: ______
PCP: ______
Downers: ______
Barbiturates: ______
Cocaine: ______
LSD: ______
Uppers: ______
Amphetamines: ______
Hashish: ______
Drug use frequency:
Consider drug use a problem:
First drug use:
Arrested for sale/possession:
Injected drugs: ______ Times:
HIV tested: ______ Result:
Hepatitis C tested: ______ Result:
G) Past Use
Age first used drugs/alcohol:
Who were you with:
Drugs used in lifetime:
Past amount of use:
Past frequency:
Family alcohol problems: ______
H) Medical/Pain Issues
Physical pain (0-10):
Physical treating physician:
Physical referral:
Psychological pain (0-10):
Source of pain:
Duration of pain:
Psychological treating physician:
Psychological referral:
Victim of abuse: ______ Describe:
Victim of domestic violence: ______ Describe:
Signatures
Patient Signature: Date:
ASAP Staff Signature: Date:
Physician Signature: Date: