Health Questionnaire

Health Questionnaire
Date*

MonthDayYear
Date
Patient’s Name *

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Emergency contact

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship to you
Marital Status

SingleMarriedDivorcedSeparatedWidowOther
Occupation
Employer, # of years
List education completed (high school, GED, college, trade or vocational school)
Current Living Situation

alonewith spouse/matewith parentsOther
Spouse/partner name (If No Spouse write N/A)

First NameLast Name
Spouse/partner occupation
Children

YesNo
Siblings

YesNo
Names & Ages: (Please answer below.)
Primary Care Physician
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Therapist ( If you dont have a therapist write N/A)
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Pharmacy
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Referred by
Reason for Today's Visit
List Your Goals you want to achieve
Have you ever seen a Psychiatric Provider before?

YesNo
(If yes, when and why?)
Have you ever took any medications for your mental health? If so please list all medications taken and dose
Have you ever been psychiatrically hospitalized?

YesNo
(If yes, please provide what hospital, when and the reason)
Have you ever had any thoughts of suicide?

YesNo
Have you ever made a suicide attempt?

YesNo
If so, when & why, indicate last time you had any suicidal thoughts, plan or attempt?
SYMPTOM SCREEN
Have you ever been sad or depressed for more than two weeks?

YesNo
Have you ever had so much energy that you didn’t need to sleep, and made big plans or bad decisions?

YesNo
Have you ever been so anxious that you couldn’t do anything, or even leave the house?

YesNo
Do you often feel that you need to count, check or clean things in a special way?

YesNo
Do you ever have several minutes of extreme anxiety and fear that comes out of the blue?

YesNo
Do you ever feel that you can’t control your thoughts or that people can read or control your mind?

YesNo
Have you ever thought about someone so much that you followed them?

YesNo
Do you have trouble sleeping?

YesNo
Do you have any medical illnesses?

YesNo
(If yes, please provide details of any questions you answered YES)
Allergies to any foods or medications?

YesNo
(If yes, please indicate all allergies)
MEDICATIONS

List your current and past prescribed medications and over-the-counter drugs such as vitamins and herbal supplements.

Rows	Medication	Dose	Dates taken	Effectiveness	Side Effects	Reason for stopping
1.
2.
3.
4.

HEALTH HABITS
Exercise

Sedentary (No exercise)Mild exercise (i.e. climb stairs, walk 3 blocks)Occasional vigorous exercise (i.e. work or recreation, less than 4x/week for 30 min.)Regular vigorous exercise (i.e. work or recreation 4x/week for 30 minutes)
Caffeine

NoneCoffeeTeaSoda
# of cups/cans per day
Do you drink alcohol?

YesNo
(If yes, what kind?)
How many drinks per week?
Are you concerned about the amount you drink?

YesNo
Have you ever experienced blackouts?

YesNo
Are you prone to ”binge” drinking?

YesNo
Have you received treatment for drug or alcohol addiction?

YesNo
Do you use tobacco?

YesNo
Cigarettes #/day
other
# of years, or year quit
Do you currently use recreational or street drugs?

YesNo
(If yes, what kind?)

CocaineHeroinEcstasyPCPAmphetamineMarijuanaGHBLSDBath Salts
If yes, describe use and frequency and last use
FAMILY MENTAL HEALTH HISTORY
Do you have family history with mental health or substances use?

YesNo
(If yes, please explain)
SOCIAL HISTORY
Where were you born and raised?
Did you develop normally as a child? (physically and mentally)

YesNo
Did you have any problems in school? (discipline or behavioral)

YesNo
Please check any of the following that applied to your childhood (please describe below)

HyperactivityUnhappy childhoodHappy childhoodConduct problemsLearning difficultiesHead injuryNight terrorsFears/worriesStammering
Abuse

physicalemotional,sexual
Interests and hobbies
Work History
Relationship History
Sexual Orientation
LEGAL HISTORY
Have you ever been arrested?

YesNo
(If yes, please describe.)
Should be Empty:

Health Questionnaire

SYMPTOM SCREEN

MEDICATIONS

HEALTH HABITS

FAMILY MENTAL HEALTH HISTORY

SOCIAL HISTORY

LEGAL HISTORY