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Attachment 11A
Page 1 of 2
RIVERSIDE COUNTY DEPARTMENT OF MENTAL HEALTH
ADULT MEDICAL HISTORY SUMMARY
Part I – TO BE COMPLETED BY PATIENT OR PATIENT INFORMANT (Please Print)

Patient’s Name:

_________________
(First) (Middle) (Last)
(Maiden)
Informant
Patient/Relationship:
_________________

Current Physician:

_________________
(Address/City)

Date of Last Physical: ___________________

Do you have allergies? Yes No

PLEASE CHECK ALL OF THE FOLLOWING WHICH YOU HAVE HAD IN THE PAST:

_________________
_________________
SUBSTANCES YOU ARE ALLERGIC TO:
______________________________

DESCRIPTION
ALLERGIC
RESPONSE/NATURE
REACTION:
______________________________
WITHIN THE PAST YEAR HAVE YOU TAKEN PRESCRIBED OR OTHER MEDICATIONS FOR:

Nutrition/Weight Problem? Name: ______________________________________ Currently Using? Nerves/Anxiety/Depression? Name: ______________________________________ Currently Using? Name: ______________________________________ Currently Using? Name: ______________________________________ Currently Using? Are you taking, or have you taken Antabuse?
Consumer Signature:
Attachment 11A
Part II – HISTORY TAKING FOR STAFF USE ONLY (Use Additional Sheets if Necessary)
SIGNIFICANT PAST ILLNESS, ACCIDENTS, HOSPITILIZATION, and MEDICAL PROBLEMS: SIGNIFICANT FAMILY HEALTH HISTORY AND PROBLEMS: ________________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 5. PAST ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 6. OTHER MEDICATIONS (Includes Prescription and Non-Prescriptive Drugs): ____________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________ CURRENT USE OF ALCOHOL AND/OR STREET DRUGS: ________________________________________________________________________________________________________________________________________________________________________________________________________________________ 8. PAST USE OF ALCOHOL AND/OR STREET DRUGS: ________________________________________________________________________________________________________________________________________________________________________________________________________________________ IF ENTRIES ARE MADE TO EITHER QUESTION 7 OR QUESTION 8, PLEASE COMPLETE DRUG/ALCOHOL ASSESSMENT. COMMENTS: _______________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________ _____________________________________________ _____________________________________________

Source: http://rcdmh.org/opencms/english/mental_plan/2010_Outpatient_Attachments/Attachment_11A_Adult_Medical_Historyx_English.pdf

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