Health History
Please complete this form as best you can to help us personalize your treatment.
intake_id
Identifier for intake flow: {FirstName_|_Email} . If this is filled Email and Name will be hidden
Email
*
example@example.com
Name
*
First Name
Last Name
In a few sentences, what prompted you to seek treatment at Heading?
Feel free to describe how you've been feeling, any recent events/life changes, etc.
Please list any previous or current mental health specialists you have or are currently seeing:
If not applicable, please enter NA or skip to the next field.
Please list previous and/or current medical & mental health diagnoses:
If not applicable, please enter NA or skip to the next field.
Previous psychiatric medications:
Name of Medication / Max Dose / Length of Time on Medication - If not applicable, please enter NA or skip to the next field.
Previous psychiatric hospitalizations:
If not applicable, please enter NA or skip to the next field.
Date of most recent admission of psychiatric hospitalization:
-
Month
-
Day
Year
Can be an estimate if needed - If not applicable, please enter NA or skip to the next field.
Previous interventional treatments:
(i.e.: electroconvulsive therapy (ECT), TMS, Ketamine Therapy, Spravato, etc. - Please include dates & duration)
Please list any surgical history:
(Please include dates if available)
Please list your family medical & psychiatric history:
(History for parents, siblings, & children)
Previous or current substance use:
Substance Use Length of Time / Last Used - If not applicable, please enter NA or skip to the next field.
Previous suicide attempts:
Year / Additional Details - If not applicable, please enter NA or skip to the next field.
Have you experienced physical, sexual, or emotional abuse/trauma?
Yes
No
Prefer not to say
Please describe any abuse or childhood trauma you have experienced:
(If you prefer not to say or not applicable, type NA or skip to the next field)
Do you have any medication or environmental allergies? If yes, please describe as well as the reaction(s):
Do you have children? If so, how many?
Please describe your current home environment:
Do you live alone or with others (family/a spouse/a roommate)? Are you happy with your living situation or does it create stress in your life?
What is your highest level of education?
Are you currently employed? If yes, what is your occupation?
Do you have any current or historical legal issues?
Yes
No
Prefer not to say
Do you have a religious preference? If yes, please describe:
Next
Should be Empty: