TeleHealth Intake Form

TeleHealth Intake Form
Name*

Igoa
Birth Date*

MonthDayYear
Aso Fanau
Village*
Gender*

FemaleMale
Are you Employed*

YesNo
Are you a Student*

YesNo
Marital Status*

SingleMarriedDivorcedWidow
Email *
Phone Number *
Address*

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Information*
Check all symptoms that apply*

Sad/depressed moodLoss of interest/pleasureFeeling worthless/guiltWithdrawn/Social IsolationIrritability/outbursts of angerWeight gain/lossAppetite increase/decreaseSleep disturbanceCrying spellsDifficulty concentratingInflated self-esteemGrandiosityTalkativeFlight of ideasDistractibilityUnrestrained buying spreesSexual indiscretionsExcessive pleasure activitiesMuscle tensionHeart palpitationsSweating not due to heatTrembling/shakingShortness of breathFeeling of chokingChest pain/discomfortFeeling dizzy/lightheadedCompulsionsFear of losing controlRecurrent/persistent thoughtsRecurrent/intrusive memoriesLaxative/diuretic abuseTrouble following directionsTouchy/easily annoyedThoughts of SuicideHomicidal IdeationPoor impulse controlRelationship difficultiesDeliberate property destructionOther
Please select the option that applies regarding your smoking or vaping habits

None0 -1 times a day2 - 10 times a day10+ packages a day
Average # alcoholic drinks per week?
Average hour of sleep per week?
Average # of workouts per week?
List any chronic health problems you may have
List out all current medication
List out allergies
Have you received any mental health outpatient treatment services? If so, please explain. *
Have you been hospitalized? If so, please explain.
These Questions Refer To The Past 12 months

The following questions refer to information about your possible involvement with drugs in the past 12 months.

Type a question

	Yes	No
Have you used drugs other than those prescribed for medical reaaons?
Do you abuse more than one drug at a time?
Are you unable to stop using drugs when you want to?
Have you ever had blackouts or flashbacks as a result of drug use?
Do you ever feel bad or guilty about your drug use?
Does your spouse (or parents) complain about your involvement with drugs?
Have you neglected your family because of your use of drugs?
Have you engaged in illegal activities in order to obtain drugs?
Have you ever experienced withdrawal symptoms (feel sick) when you stopped taking drugs?
Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, bleeding)?

Is there anything else that you would like us to know?
What problems are you seeking help for?
What days work best for you?

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
What time works best for you?

MorningAfternoonEvening
Date

MonthDayYear
Date
Signature*

Clear
Should be Empty:

TeleHealth Intake Form

These Questions Refer To The Past 12 months