Name *

First Name

Last Name

Date *

MM

DD

YYYY

Date of Birth

MM

DD

YYYY

*

Do you give permission for ongoing regular updates to be provided to your primary care physician?

Yes

No

Primary Care Physician's Phone Number *

(###)

###

####

Are you currently under the treatment of psychologist/psychiatrist?

Yes

No

Numbner of psychologist/psychiatrist. *

(###)

###

####

Current Symptoms Checklist *

Check once for any symptoms present, or history of symptoms.

Depressed mood

Racing thoughts

Excessive worry

Unable to enjoy activities

Impulsivity

Anxiety attacks

Sleep pattern disturbance

Increase risky behavior

Avoidance

Loss of interest

Increased libido

Hallucinations

Concentration/forgetfulness

Decrease need for sleep

Suspiciousness

Change in appetite

Excessive energy

Excessive guilt

Increased irritability

Fatigue

Crying spells

Decreased libido

Have you ever had feelings or thoughts that you didn't want to live? *

Yes

No

Do you currently feel that you don't want to live?

Yes

No

Family Psychiatric History

Has anyone in your family been diagnosed with or treated for:

Bipolar disorder

Depression

Anxiety

Anger

Suicide

Schizophrenia

Post-traumatic stress

Alcohol abuse

Other substance abuse

Violence

Have you ever been treated for alcohol or drug use or abuse?

Yes

No

Have you ever felt you ought to cut down on your drinking or drug use?

Yes

No

Have people annoyed you by criticizing your drinking or drug use?

Yes

No

Have you ever felt bad or guilty about your drinking or drug use?

Yes

No

Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover?

Yes

No

Do you think you may have a problem with alcohol or drug use?

Yes

No

Have you used any street drugs in the past 3 months?

Yes

No

Have you ever abused prescription medication?

Yes

No

Check if you have ever tried the following

Methamphetamine

Cocaine

Stimulants (pills)

Heroin

LSD or Hallucinogens

Marijuana

Pain killers (not as prescribed)

Methadone

Tranquilizer/sleeping pills

Alcohol

Ecstasy

Currently?

Yes

No

How you ever smoked cigarettes?

Yes

No

In the past?

Yes

No

Pipe, cigars, or chewing tobacco: Currently?

Yes

No

In the past?

Yes

No

Family Background and Childhood History:

Were you adopted?

Yes

No

Did your parents' divorce?

Yes

No

Do you have a history of being abused emotionally, sexually, physically or by neglect?

Yes

No

Are you currently:

Working

Student

Unemployed

Disabled

Retired

Honorable discharge

Yes

No

Are you currently:

Married

Partnered

Divorced

Single

Widowed

If not married, are you currently in a relationship?

Yes

Noi

Are you sexually active?

Yes

No

How would you identify your sexual orientation?

straight/heterosexua

lesbian/gay/homosexual

bisexual

transsexual

unsure/questioning

asexual

prefer not to answer

Have you had any prior marriages?

Yes

No

Do you have children?

Yes

No

Do you belong to a particular religion or spiritual group?

Yes

No

Do you find your involvement helpful during this illness, or does the involvement make things more difficult or stressful for you?

more helpful

stressful

Date 2

MM

DD

YYYY

Date 3

MM

DD

YYYY

Phone 1

(###)

###

####