Name First
Middle Initial:
Last
Date
Age:
Date of Birth
Gender (select)
Male
Female
Race (select)
Caucasian
African American
Native American
Asian/Pacific Islander
Hispanic/Latin
Other
Contact Numbers: Primary
Secondary
Email
Home Address
City
State
Zip/Postal
Length of Residence here
Who lives with you?
Person to notify in case of emergency:
Name
Relationship
Telephone number
SYMPTOMS:
What are your symptoms / what bothers you most (in priority order)?
Please indicate how much each symptom bothers you:
(1=A little; 2=Moderate; 3=A lot; 4=Extremely, place number after the symptom)
4
3
2
1
4
3
2
1
4
3
2
1
4
3
2
1
4
3
2
1
4
3
2
1
4
3
2
1
4
3
2
1
4
3
2
1
Family History of mental health problems:
None
Unknown
Relationship
Diagnosis
Treatment
Staff Comments
OTHER SYMPTOMS: (select Yes or No)
1. There are weeks that I feel charged with energy and require almost no sleep.
Yes
No
Comments (for staff use only)
2. I have had anxiety attacks that come on me suddenly and unexpectedly
Yes
No
Comments (for staff use only)
3. I have a strong urge to repeat certain acts over and over.
Yes
No
Comments (for staff use only)
4. Disturbing thoughts come into my mind that I cannot get rid of.
Yes
No
Comments (for staff use only)
5. I sometimes have trouble controlling my anger.
Yes
No
Comments (for staff use only)
6. I have experienced a traumatic event and have distressing memories of the event.
Yes
No
Comments (for staff use only)
7. I periodically injure myself on purpose.
Yes
No
Comments (for staff use only)
8. I think about suicide or have made a suicide attempt.
Yes
No
Comments (for staff use only)
9. I am afraid of certain places, objects, or animals and go out of my way to avoid them.
Yes
No
Comments (for staff use only)
10. I get unusually fearful in social situations.
Yes
No
Comments (for staff use only)
11. As a child I was frequently in trouble for fighting, lying, stealing or skipping school.
Yes
No
Comments (for staff use only)
12. I have had an eating disorder
Yes
No
Comments (for staff use only)
PERSONAL HABITS:
Do you currently use tobacco?
How much per day?
How many alcoholic beverages do you consume in a typical week?
Are you willing to discontinue all alcohol use if you participate in a study?
Yes
No
When was the last time that you used recreational drugs (e.g. marijuana, cocaine, methamphetamine, etc.)? Please select:
last week
last month
last year
last 5 years
last 10 years
over 10 years
never
Comments (for staff use only):
LEGAL HISTORY:
Are you currently involved in a legal dispute?
Yes
No
If yes, please explain:
Have you ever been arrested?
Yes
No
If yes, please explain:
EDUCATION AND WORK HISTORY
Level of Education
Less than High School
High School/GED
Some college
College Grad
While attending school, what grades do/did you typically earn?
A
B
C
D
F
Are you currently employed?
Yes
No
Hours worked per week
What is your job?
How long have you had this job?
How many jobs have you had in the last ten years?
Length of longest job:
Have you ever served in the military?
Yes
No
What branch?
When?
Comments (for staff use only):
RELATIONSHIP HISTORY:
Select All That Apply:
Single
Married
Seperated
Divorced
Widowed
Partnered
Do you have children?
Yes
No
If yes: How many?
What are your most important relationships (family, friends, children, partners, etc.)?
Which relationships are most difficult for you?
Thank you for completing this confidential form. You will have the opportunity to discuss your answers
when you meet with your doctor.
For staff use only: Date reviewed with clinician:___________________________
All entries in __________ink made by _______________upon review with the patient
Medical History Questionnaire
Name
Date
DOB
Please check yes or no for
each condition listed below
Ear, Nose, Throat Disease?
Yes
No
Description
Start Date
Stop Date
Eye Disease?
Yes
No
Thyroid Disease / Goiter?
Yes
No
Heart Disease?
Yes
No
High Blood Pressure?
Yes
No
High Cholesterol?
Yes
No
Lung Disease?
Yes
No
Diabetes?
Yes
No
Liver / Gallbladder Disease?
Yes
No
Stomach / Intestinal Disease?
Yes
No
Kidney / Bladder Disease?
Yes
No
Prostate Disease?
Yes
No
Breast Disease?
Yes
No
Uterine / Ovarian/ Cervical Disease?
Yes
No
Epilepsy / Seizures/Stroke or TIA?
Yes
No
Neurological Disease?
Yes
No
Bone or Joint Disease?
Yes
No
Skin Disease?
Yes
No
Psychological Problems?
Yes
No
Blood Disease?
Yes
No
Cancer or Tumors?
Yes
No
Current method of birth control?
Yes
No
Other?
Yes
No
SURGERIES or HOSPITALIZATIONS:
None
Surgery / Hospitalization
Date
Reason
ALLERGIES: Please list all including environmental, food, & medication
Allergy
Reaction
Date Started
Date Ended
MEDICATIONS: What over-the-counter or prescription medications, including vitamins and herbal preparations, have you taken in the last 3 months?
None
Medication
Dose
# Times / Day
Reason
Start Date
End Date
Cont'd?
Cont'd?
Cont'd?
Cont'd?
Cont'd?
Cont'd?
Cont'd?
Cont'd?
Reviewed by:
Date
Submit
If you are human, leave this field blank.
Thanks! Your form has been submitted.
This would be an aweber form.
