Highpoint Client Intake Form Pt 1 The form filler needs to input the email address Email * Medical / Psychiatric Data医药/精神病况资料List Medical / Psychiatric ConditionsAsthma 哮喘Diabetes 糖尿病Epilepsy 癫痫Gastric 胃病Hepatitis 肝炎Hypertension 高血压Heart Problem 心脏病Stroke 中风HIV 爱滋病High Cholesterol 高胆固醇Arthritis关节炎Ulcer 胃溃疡Insomnia 失眠Schizophrenia 精神分裂Depression 忧郁症Seizure 癫痫OthersOther Medical / Psychiatric Conditions (please specify)Institution 机构Hospitalized 住院历史Medications 服用药物Medications Allergy 药物过敏Attempt suicide 企图自杀PPO 个人保护令Aggression 暴力倾向Remarks on Medical / Psychiatric ConditionsSubstance Addictions 物质成瘾Opiates Length of use- Opiates Frequency- Opiates Last Used- Opiates QuantityHeroin Length of use- Heroin Frequency- Heroin Last Used- Heroin QuantityIce Length of use- Ice Frequency- Ice Last Used- Ice QuantityPill (Dormicum) Length of use- Pill (Dormicum) Frequency- Pill (Dormicum) Last Used- Pill (Dormicum) QuantityCodeine (Cough syrup) Length of use- Codeine (Cough syrup) Frequency- Codeine (Cough syrup) Last Used- Codeine (Cough syrup) Last Used- Codeine (Cough syrup) QuantityInhalants (Glue sniffling) Length of use- Inhalants (Glue sniffling) Frequency- Inhalants (Glue sniffling) Last Used- Inhalants (Glue sniffling) QuantitySubutex Length of use- Subutex Frequency- Subutex Last Used- Subutex QuantityCannabis (marijuana) Length of use- Cannabis (marijuana) Frequency- Cannabis (marijuana) Last Used- Cannabis (marijuana) QuantityEcstasy Length of use- Ecstasy Frequency- Ecstasy Last UsedEcstasy QuantityNew Psychoactive Substances Length of use- New Psychoactive Substances Frequency- New Psychoactive Substances Last Used- New Psychoactive Substances QuantityAlcohol Length of use- Alcohol Frequency- Alcohol Last Used- Alcohol QuantitySmoking Length of use- Smoking Frequency- Smoking Last Used- Smoking QuantityOther substances (please specify)Other Length of use- Other Frequency- Other Last Used- Other Quantity Save Cancel
