Client Check in
Client's Name Today's Date
Since your last appointment have you used any of the following?Caffeine Caffeine YesNo
Drugs not prescribed YesNo
Since your last appointment: Did you see a doctor YesNo
Were you prescribed new meds? YesNo
Did you complete any labs? YesNo
Did you use prescription birth control? YesNo
Are you pregnant or intending to be? YesNo
Did you attend therapy or group? YesNo
Did you have any hypomanic or manic days? YesNo
Did you have hallucinations or hear voices? YesNo
What social activities or hobbies have you been enjoying?
What type of/how much exercise have you performed?
Do you feel rested most days? YesNo
NEW symptoms or medical problems since your last appointment: recent fever changers in vision palpitations blood in urine recent night sweats loss of vision chest pain flank pain change in weight ear pain swelling of extremities muscle pain headaches difficulty swallowing nausea joint pain weakness neat / cold intolerance vomiting easy brusing numbness excessive thirst diarrhea gums bleeding shortness of breath abdominal pain hay fever rashes coughing difficulty urinating lupus changes in skin wheezing frequent urination seizure (Date:)
Pain Intensity- Please circle the number, or range of numbers. that best describe your pain. 0 being no pain and 10 being worst pain imaginable.
On a 'good' day: 0...... 1...... 2..... 3...... 4...... 5...... 6...... 7...... 8...... 9...... 10
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Client Check in
Agree & Sign