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INTAKE VITAL INFO
PART I



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Chief Complaint - Reason for Contact

Personality Traits and Status for ' . $Tttitle . ' ' . $fullname_consent . '



Gender
My Order of Birth
1st, 2nd, 3rd...
    • Num of Siblings
    male - female
  •       
Native language
When I was born My Natural Parents were ?
I Reside with
My Marital Status
My Profession or Trade
Highest Level of Education
Highest Level of Education
Religious Heritage
Practicing Status

Do Any Blood-Relative now, or in the past, have any mental Health Issues.
If you check any of the boxes below - Please explain below.

Maternal Side

    • Paternal Side

Mental Health Issues
Drugs, Alcohol, Gambling, Addictions

Add comments Re: Family and Relatives / Mental Health Issues, and/or Personality quirks such as : Disorganized, Perfectionistic, Controlling, Temperamental, Anxious, etc.

Add comments Re: Family / Blood Relatives :Alcoholism, Gambling, Rx-Drugs, and/or any Substance Abuse, or Addictions