Medical Questionnaire

(Needs to be filled out prior to Appointment)

***Please bring all medications, supplements, herbs, regularly used over-the-counter medications to first appointment.***

Your Name :

Date :

Email:

Phone Number where we may leave a message:

Date of Birth:

Age :

Sex: MaleFemaleUnlisted

Unlisted :

Address :

Referring Counselor and/or Clinic Name:

Primary Care Provider:

Psychiatrist:

Drug/Food Allergies:

Current Medications (Including over the counter/supplements/herbs):

Medical Conditions:

Office Use:

Face to Face:

Clinical:

Please Check anything that applies to you :

DepressionSadnessDecreased energyLow motivationHopelessnessGuiltThoughts of suicideWant to be aloneDifficulty concentratingWorthlessnessLow interest in activitiesIrritabilityDifficult sleepingWant to sleep excessivelyShameShame Have a suicidal planLost weight in the last 6 monthsGained weight in the last 6 months

Please Check anything that applies to you :

Days with significant increase of energyDecreased need for sleepMood swingsImpulsive decisionsRisk taking behaviorsUnusual activitiesReckless spendingGrandiosityHyper-sexualHyper-religiousRapid speechRacing thoughtsIrritability

Please Check anything that applies to you :

Increased stressFast beating heart when anxiousPanic AttacksFeeling something bad is going to happenPhobias (irrational fear)

Please Select the Answer Yes or No to anything that applies to you below :

Do you ever hear or see things that other people cannot ?

YESNO

Do you ever feel like other people are watching you ?

YESNO

Do you ever feel like other people are talking about you ?

YESNO

Do you ever feel like other people are laughing at you ?

YESNO

Do you have any special powers or gifts ?

YESNO

Do you know other people who have special powers or gifts ?

YESNO

Do you ever feel like other people can read your thoughts or control you ?

YESNO

Do you ever feel like someone else is putting thoughts inside your head ?

YESNO

Do you ever get messages from outside forces ?

YESNO

Do doctors have a hard time figuring out why you are sick ?

YESNO

Please Check the answer that best applies to you:

Do you have any activity or chore that you must complete every day ?

YESNO

Do you have unwelcome or involuntary :

ThoughtsImagesUnpleasant ideasRepetitive thoughtsObsessive thoughts

Please Circle the answer that best applies to you:
Have you ever had a traumatic event that causes:

Flash BacksNightmaresAvoid people place or things that would remind you about the eventUnpleasant memories that come out of the blue

If so briefly describe the traumatic event :

Past Mental Health History

Have you ever been diagnosed or thought you have: (Please check all that apply)

ADDADHDAggression Adjustment DisorderAlcoholism Substance AbuseAlzheimer’s DiseaseAmnesiaAnorexiaAntisocialAnxietyAttempted SuicideBipolar DisorderBorderline DisorderBulimiaDeliriumDementiaDepressionGeneralized Anxiety DisorderImpulse-Control DisorderManic Depressive DisorderOCDOppositional Defiant DisorderPanic AttacksPhysical AbusePsychosomaticPTSDSchizophreniaSeparation Anxiety DisorderSexual AbuseSexual OffenderSleep DisorderSocial PhobiaTourette’s Disorder

Have you ever been to a Psychiatrist or Counselor :

Year or Age	Treatment Provider or Clinic	How often seen





Was this Psychiatrist/Counselor helpful:
Diagnoses (if any) :

Have you ever been prescribed psychiatric medicines?

Year or Age	Medication Name	How often taken ?

Have you ever been hospitalized for Mental health or Substance Abuse ?

Year of Hospitalization	Name of Hospital or Center	Length of Stay	Sobriety length after stay (if applicable)



Where the hosplitalizations voluntary or involuntary :
Was your stay helpful :
Have you ever had ECT (electroconvulsive therapy) :

Substance History

How much caffeine (chocolate/coffee/soda) do you consume in a day:

At what age did you start smoking :

Age quit :

Cigarettes per day :

How old were you when you first started drinking :

Age quit :

Currently or in the past how much alcohol a day :

Beer :

Wine :

Hard Liquor :

Have you ever abused any of the following prescription drugs: (Please check all that apply)

AdderallAlprazolamAmbienAtivanAvandiaClonazepamCodeineDarvocetDarvonDemerolDexedrineDiazepamDilaudidDolophineFentanylHydrocodoneKadianKlonopinLibriumLorazepamLorcetLornotilLortabLunestaMethadoneMorphoneNorcoOxycodoneOxyContinPercocetPercodanRestorilRitalinSuboxoneTalwinTramadolUltramValiumVicodinVyvanseXanaxZolpidemCough Syrup

Other :

Approximately how much were you using and for how long :

Are you now or have you ever used street drugs : (Please tik all that apply)

AmphetaminesBarbituatesCocaineCrackCrankEcstasyGHBHeroinHuffingKetamineLSDMarijuanaMescaline HashMethamphetamineNembutalNitrous OxidePCPPeyoteOpiumShroomsQuaaludesSteroidsWhippits

Other :

Approximately how much were you using and for how long :

Family Medical History / Medical Diagnoses :

Father :

Siblings :

Mother:

Children :

Family Psychiatric History / Psychiatric Diagnoses :

Has anyone in your family (blood relative) suffered from emotional, problems, nervous problems, depressions or other stress conditions? If so, please list the family member(s) and briefly describe the problem.

Has anyone in your family (blood relative) had problems with drugs or alcohol? If so, please list the family member(s) and briefly describe their problem.

Has anyone in your family ever attempted or committed suicide :

YESNO

Did you have any juvenile behavioral problem(s) : (Please tik all that apply)

Cruelty to AnimalsDrug or Alcohol ProblemsFightingFire SettingJuvenile Court DifficultiesLyingRunning AwayShopliftingSkipping School

Social History

Where do you presently live?

Highest grade of school completed :

Do you have biological children? Please list oldest to youngest (include ages) and if they are male or female.

What is your religious preference ?

What is your current employment ?

List your hobbies and social interest :

Office Use Only :

B/R :

CH”*” :

V/E/P/S :

PERP :

Legal :

Financial :

Support :

Medical / Surgical History

Major Medical Diagnoses: (for example; high cholesterol, low thyroid, heart problems)

Have you ever had a major surgery :

Year :

Surgery :

Have you ever had a head injury in which you were knocked unconscious? If so, please list your age at the time of the injury and how long you were unconscious.

Year/Age:

Time Unconscious :

Injury :

Please tik all that apply to you within the last month only:

Abdominal PainAppetite increase, decreaseBlack or Tarry stoolsBowel changesBurning tingling sensation in finger and/or toesChest pain at this time (related to anxiety)ChillsConfusionCongestionConstipationCoughDiarrheaDifficult UrinationDizziness when standingDysphasiaEasy BleedingEasy BruisingExcess FatigueExcessive need to eatExcess desire to drink liquidsExcessive SweatingExcessive UrinationFaintingFallsFeverFrequencyHearing lossHeartburnHeat or Cold intoleranceHesitancyHoarsenessMouth pain or lesionsNasal congestionNauseaNight sweatsNight time urinationNumbnessOngoing HAPainful UrinationPalpitations (related to anxiety)Recent weight loss or gainRinging in earsSeizuresSOB (related to anxiety)Sore ThroatSwelling in your legsSwollen GlandsTinglingTremorsUrgencyUrinary IncontinenceVision ChangesVomitingWeaknessWheezing

On your Body:

RashesLumpsSoresUlcersLesions