Client Check in

                                                    ECR #  

Client's Name      Today's Date   

Since your last appointment have you used any of the following?
Caffeine Caffeine

12oz. per day:


    Grams per week :


  Drinks per week:


  Cigarettes per day 

Drugs not prescribed

   Type Amount    Per  

Since your last appointment:
Did you see a doctor

  When :

Were you prescribed new meds?

  What Meds?

Did you complete any labs?

  What Labs :

Did you use prescription birth control?

  What Type 

Are you pregnant or intending to be?

Did you attend therapy or group?


Did you have any hypomanic or manic days?


Did you have hallucinations or hear voices?

  Frequency ?  

What social activities or hobbies have you been enjoying?   

What type of/how much exercise have you performed?   

Do you feel rested most days?

  How many hours of sleep do you averate at night?   

NEW symptoms or medical problems since your last appointment:


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:

On a 'bad' day :

Leave this empty:

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Signature Certificate
Document name: Client Check in
lock iconUnique Document ID: 11704a30f7e5747f9869d910f021538960dcf11d
Timestamp Audit
August 23, 2021 12:11 pm PDTClient Check in Uploaded by Adam Falk - IP
August 31, 2021 9:26 am PDTLane MAA - added by Adam Falk - as a CC'd Recipient Ip: