OTHER SYMPTOMS: (select Yes or No)
1. There are weeks that I feel charged with energy and require almost no sleep.
2. I have had anxiety attacks that come on me suddenly and unexpectedly
3. I have a strong urge to repeat certain acts over and over.
4. Disturbing thoughts come into my mind that I cannot get rid of.
5. I sometimes have trouble controlling my anger.
6. I have experienced a traumatic event and have distressing memories of the event.
7. I periodically injure myself on purpose.
8. I think about suicide or have made a suicide attempt.
9. I am afraid of certain places, objects, or animals and go out of my way to avoid them.
10. I get unusually fearful in social situations.
11. As a child I was frequently in trouble for fighting, lying, stealing or skipping school.
12. I have had an eating disorder
Are you willing to discontinue all alcohol use if you participate in a study?
When was the last time that you used recreational drugs (e.g. marijuana, cocaine, methamphetamine, etc.)? Please select:
Are you currently involved in a legal dispute?
Have you ever been arrested?
EDUCATION AND WORK HISTORY
While attending school, what grades do/did you typically earn?
Are you currently employed?
Have you ever served in the military?
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
Please check yes or no for
each condition listed below
Ear, Nose, Throat Disease?
Thyroid Disease / Goiter?
High Blood Pressure?
Liver / Gallbladder Disease?
Stomach / Intestinal Disease?
Kidney / Bladder Disease?
Uterine / Ovarian/ Cervical Disease?
Epilepsy / Seizures/Stroke or TIA?
Bone or Joint Disease?
Cancer or Tumors?
Current method of birth control?
ALLERGIES: Please list all including environmental, food, & medication
MEDICATIONS: What over-the-counter or prescription medications, including vitamins and herbal preparations, have you taken in the last 3 months?