Treatment History Sample Clauses

Treatment History. Document the history of all treatment past and present: a. Behavioral health treatment i. List past and present treatment youth has participated in: Dates (or estimation) of Estimated helpfulmess of treatment and reason for Type of treatment Agency/provider termination ii. Barriers to behavioral health treatment: Be specific about challenges that impact(ed) treatment: transportation, finances, negative rapport, lack of involvement, other disruptions, etc. b. Medication therapies i. List medications tried in the past: Medication Dosage Frequency Youth’s age and response to medication Reason for changing or terminating medication ii. Barriers to behavioral health treatment: Be specific about challenges that impact(ed) treatment: transportation, finances, negative rapport, lack of involvement, other disruptions, etc. iii. List current medications: iv. Barriers to behavioral health treatment: Be specific about challenges that impact(ed) treatment: transportation, finances, negative rapport, lack of involvement, other disruptions, etc. c. Substance abuse therapies List past and present substance abuse treatment youth has participated in: Type of treatment Agency/provider

Treatment History. List below all professional and/or personal efforts that have been made to address your son/daughter’s emotional, behavioral, or substance abuse problems (i.e., therapy, hospitalizations, treatment programs, placement, etc.). List the most current treatment first; include addresses and telephone numbers. Add additional sheets if needed. Reason: Professional/Therapist: Credentials: Address: Telephone: ( ) Your assessment of treatment outcome: Reason: Professional/Therapist: _ Credentials: Address: Telephone: ( ) Your assessment of treatment outcome: Reason: Professional/Therapist: Credentials: Address: Telephone: ( ) Your assessment of treatment outcome: Reason: Professional/Therapist: Credentials: Address: Telephone: ( ) Your assessment of treatment outcome: _ Person completing form and relation:

Treatment History. If you do not have back or low back pain, skip this section and go to “past medical history” section) Which of the following caregivers have you visited prior to your arrival here? (Please provide names) □ Family Physicians (includes general practitioners, Internists, gynecologists, etc.) □ Orthopedic Surgeon □ Neurologist □ Rheumatologist □ Chiropractor □ Acupuncturist □ Physical Therapy □ Other Pain Management Which of the following test(s) have you undergone prior to your arrival today? □ X-Rays □ CAT Scan □ MRI Scan □ EMG test □ Discogram □ Neural Block □ Myelogram Have you had any of the following interventions done for your neck or low back pain? □ Trigger Point Injections □ Ultrasound □ Heat □ Cold □ Cryotherapy □ TENS/ nerve stimulator □ Discography □ Facet □ Sacroiliac □ Other Joint injections Have you ever had any of the following surgical interventions (for neck and back pain)? □ Back Surgery: fusion Date: _ □ Back Surgery: non-fusion Date: _ □ Back Surgery: Spinal Cord Stimulator Date: _ List all Surgeries and their DATES: Please list all, if any DRUG ALLERGIES and their REACTIONS: Do you take any of the following? □ Aspirin □ Coumadin □ Plavix □ Heparin □ Pletal □ Lovenox □ Ticlid □ Effient Please list all MEDICATIONS