PSYCH QUESTIONNAIRE

PSYCH QUESTIONNAIRE
VITAL TOTAL HEALTH Medical Group, Inc.

Walnut Creek - San Francisco - Oakland - Pleasanton - Folsom - Beverly Hills

www. VitalTotalHealth.com www. VitalOncall.com

Central Phone and Fax (925) 388-9800
Name*
Today's Date
Date of Birth*

MonthDayYear
Date
Age*
RT
LT
Height
Weight
CHIEF COMPLAINTS
PROBLEMS: Check all that applies*

Chronic PainSubstance UseAnxietyDepressionBipolarOCDPTSDDecreased Memory or CognitionADHDESA Letter (Emotional Support Animal)
Please Check All that Applies*

Nervous, restless, tenseSense of PanicTrouble concentrating, excessive worryLoss of interest or pleasure in most normal activities, apathySadness, emptiness or hopelessnessTired and lack of energy, small tasks take extra effort, excessive sleepReduced appetite and weight lossIncreased cravings for food and weight gainFeelings of worthlessness or guilt, fixating on past failures, self-blameJumpy, wiredAgitated, increased activity, distractibleIntense excitement or happinessDecreased sleepTalkative, racing thoughtsFear of contamination or dirtDoubting, having difficulty tolerating uncertaintyNeeding things orderly and symmetricalUnwanted thoughts, including aggression, sexual, religious thoughtsThoughts about losing control and harming self or othersHave you had a life threatening event or a perceived life threatening eventIntrusive thoughts, nightmares, flashbacksAvoidance of outside reminders of life-threatening eventAnxious stateChanges in mood, anger, irritability, reduced interestChanges in thinking, negative thoghts, self-isolationDrinking excessive alcoholUsing or used Street DrugsCarelessness, lack of attention to detailContinually starting new tasks before finishing old onesPoor organizational skillsInability to focus or prioritizeContinually losing or misplacing thingsForgetfulnessRestlessness and edginessDifficulty keeping quiet, speaking out of turnBlurting out responses, interrupting othersMood swings, irritability, quick temperInability to deal with stressExtreme impatienceRisk taking, with little regard for safety of self or others, reckless driving
Do you have any Stressors in your Life?

RelationshipsSchool activitiesWork difficultiesFinancesChronic PainMedical Health Issues
If there is a Pain Problem, then Check where the areas are:

Head & FaceNeckShoulderArms & ElbowsWrists & HandsChest or AbdomenPelvisUpper Mid BackLow BackHipsKneesAnkles & Feet
When did your main symptoms began?

MonthDayYear
Date
How did your main problems began?

PRIOR TREATING DOCTORS:

	Name and City
Primary Care Physician
Medical Specialist
Psychiatrist
Psychologist
Chiropractor/PT/Acupuncturist

PRIOR WORK UP FOR PRESENTING PROBLEM:

	Yes	No	Year Done	Findings
Labs
Imaging (MRI,etc)

PRIOR TREATMENT FOR PRESENTING PROBLEM:

	Yes	No	M)/YR Done	Did it help?
Medications
Hormone Therapy
Counseling
Ketamine
TMS
Residential or Hospital

PAST MEDICAL HISTORY:*

	Yes	No
Seizures
Stroke
Glaucoma
Thyroid Disease
Diabetes
High Blood Pressure
High Cholesterol
Heart disease or Irregular Heart beat
COPD or emphysema
Asthma
GERD or Reflux Gastritis
Pancreatitis
Hepatitis
Kidney problems
Prostate problems
Pelvic or Genital problems
Arthritis
Chronic Pain
Chronic Infection
Cancer
Addiction
Depression
Anxiety
ADHD

Have you had any surgeries?*

YesNo

PAST SURGERIES:

	Month/Yr	Operation Performed	Did it help?
Surgery #1
Surgery #2
Surgery #3
Surgery #4

FAMILY HISTORY: Do any family members suffer from?*

	Yes	No	Mother	Father	Siblings	Children
Thyroid Problems
Diabetes
High blood pressure
Heart Disease
Stroke
Arthritis
Cancer
Addiction
Depression
Substance Abuse

SOCIAL HISTORY:*

	Yes	No
Are you married or live with a partner?
Do you live with other people?
Do you have children?
Do you smoke cigarettes?
Do you drink alcohol daily?
Do you use any street drugs?

Do you have any ALLERGIES to Drugs or Anesthesia?*

YesNo

List Drug Allergies, if any:

	Drug Name	Reaction (Rash, swelling, shortness of breathe)
Drug #1
Drug #2
Drug #3

PRESENT MEDICATIONS: Do you take medicines, or Over-the-Counter Meds or supplements?*

YesNo

List Present Medications & OTC's:

	Drug Name	Strength	How often?	For what condition	Prescribing Physician
#1
#2
#3
#4
#5
#6
#7
#8
#9
#10
#11
#12

Have you tried any other medications in the past for your problems?*

YesNo

List Drugs used in the past for your problem:

	Medicine	Strength	Did it help?	Why did you stop?
#1
#2
#3
#4

REVIEW OF SYSTEMS General Health:*

	Yes	No
Fevers, Chills, Sweating
Sleep less than 6 hours
Headaches, Migraines
Difficulties in Vision
Difficulties in Hearing
Nasal or sinus congestion, nose bleeds, loss of smell or taste
Teeth or gum problems, sore throat, swollen glands
Chest pain, rapid or irregular heart beats, feet swelling
Shortness of breath
Wheezing, coughing
Nausea, vomiting
Heartburn, abdominal pain
Yellow jaundice
Diarrhea, constipation
Bright red blood in stool, dark stool
Poor libido
Pelvic Pain
Sexual dysfunction (male ED, female SD)
Frequent urination, Burning, Urgency, Weak urine flow
Wake up to urinate
Weakness, Fatigue
Joint pain, Muscle pain
Problems with balance
Skin rashes, Acne, Moles, Easing bruising
Hair loss
Numbness, tingling
Seizures
Forgetful
Repeatedly or overly worried, Rapid thoughts
Trouble falling asleep
Snoring
Feeling sad or depressed
Feeling hopeless, Suicidal thoughts
Weight Loss, Poor appetite
Weight gain, Excessive appetite

Signed*

Clear
Should be Empty: