Office hours: Mon-Friday 8:00am-5:00pm
Location: Las Vegas, NV 89128
Our Email : evolvingreflections@gmail.com
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Please list any medications, herbs, or supplements. Be sure to include the condition, as some medications are prescribed for off-label use. Continue a separate list if needed. If you have a complicated medical profile, please supply supporting documentation to be able to facilitate a comprehensive understanding of your health.
Medication / Supplement / Herb
Dosage
Condition
Date Began / Stopped
Prescribing provider and contact information:
Name:
Specialty:
Facility:
Phone, email, or fax:
How would you rate your current physical health?
PoorUnsatisfactorySatisfactoryGoodVery Good
Please list any specific health problems you are currently experiencing:
Please describe current use of alcohol, cigarettes, and/or recreational drugs:
Please describe previous use of alcohol, cigarettes, and/or recreational drugs:
How would you rate your current sleeping habits? PoorUnsatisfactorySatisfactoryGoodVery Good
You are having problems, in which phase of sleep are you experiencing issues? Falling AsleepStaying AsleepAwakening EarlySleep Apnea
Please list any other specific sleep problems you are currently experiencing:
Client
Family Member
Alcohol/Substance Abuse
YesNo
Anxiety
Depression
Domestic Violence
Sexual Abuse
Eating Disorders
Obesity
Obsessive Compulsive Disorder
Schizophrenia
Suicide Attempts
Other Diagnosed Mental Health Condition
Marital Status:
Never MarriedDomestic PartnerMarriedSeparatedDivorcedWidowed
If Divorced, for how long?
If Widowed, please provide your partner's details:
Name of Partner:
Year Deceased:
If Married, please provide details:
How long have you been married?
On a scale of 1-10 (best), how would you rate your relationship?
12345678910
Are you currently in a romantic relationship?
If Yes, how long?
Please list any children, their names, and ages:
Name
Age
Relationship
Name of Other Parent
If deceased, age and cause of death)
What do you enjoy about your work (full-time homemaker included)? If retired, what did you enjoy about your work?
What do you find particularly stressful about your previous work?
What do you enjoy doing in your free time?
What do you do to relax?
Do you consider yourself to be spiritual or religious? If yes, please describe your faith or belief:
What do you consider to be some of your strengths?
What do you consider to be some of your weaknesses?
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