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zOverall Health Wellness Questionnaire

LifeBack
4 Princess Rd
Suite 206
Phone 609-482-3701
Fax 609-482-3702
 Client Information
  First Name:  * Last Name:  *  
           
  Date of Birth:  * Birth Sex: 
* 
         
  Address: City:  
  State: Zip Code :  
  Phone No:  
In order to help us have a better understanding of your overall health and wellness, take a moment to answer the following questions.
1. Have you ever been in treatment for mental health concerns?    
2. Have you ever been in treatment for substance use concern?    
3. In the past year, how often have you used the following?
  Frequency of Use Average Amount
Caffeine
Tobacco
Alcohol
Prescription medication (without a prescription)
Illegal Drugs
Signature
Signer Type:  
  Client (Please click "Sign with Touch" and oversee / assist the Client in signing.)
  Other (Please enter the Name of the signer below and indicate relationship with the Client then click "Sign with Touch" and oversee / assist the signing. For example: Jane Doe, mother)
   
Name:
 
Sign with Touch
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