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Client InformationClient InformationClinic/Ward DATE: / / Clinic/Ward DATE: / / Patient MSN:4101 DEWEY AVENUE REGINA, SASKATCHEWAN S4T 1A5 TELEPHONE (306) 7662261yy/ / all all all Date of Birth: mm
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How to fill out adult client case history

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How to fill out adult client case history

01
To fill out the adult client case history, follow these steps:
02
Begin by collecting the personal information of the adult client such as their name, date of birth, contact information, and any relevant identification numbers.
03
Ask the client about their medical history, including any current or past illnesses, injuries, surgeries, or medical conditions.
04
Inquire about the client's mental health history, including any past or present mental health disorders, treatments, or medications.
05
Obtain information about the client's lifestyle and habits, such as their occupation, daily activities, exercise routine, sleep patterns, diet, and substance use.
06
Ask the client about their family medical history, including any hereditary conditions or diseases that run in the family.
07
Inquire about the client's social support system, including their relationships, living situation, and any significant life events or traumas.
08
Gather information about the client's current medications, allergies, and any ongoing medical treatments they are receiving.
09
Ask the client about their goals and expectations for seeking therapeutic services or counselling.
10
Finally, review and summarize the information provided by the client, ensuring everything is complete and accurate before documenting it in the adult client case history form.

Who needs adult client case history?

01
Any mental health professional or healthcare provider working with adult clients may need the adult client case history. This includes psychologists, therapists, counselors, psychiatrists, social workers, and other professionals involved in the assessment and treatment of adults. The case history helps these professionals understand the client's background, medical history, and current circumstances, allowing them to provide appropriate care and make informed treatment decisions.
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