Health Questionnaire
Date
*
-
Month
-
Day
Year
Date
Patient’s Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Address
*
Street Address
Street Address Line 2
City
State / 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 Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Relationship to you
Marital Status
Single
Married
Divorced
Separated
Widow
Other
Occupation
Employer, # of years
List education completed (high school, GED, college, trade or vocational school)
Current Living Situation
alone
with spouse/mate
with parents
Other
Spouse/partner name (If No Spouse write N/A)
First Name
Last Name
Spouse/partner occupation
Children
Yes
No
Siblings
Yes
No
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?
Yes
No
(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?
Yes
No
(If yes, please provide what hospital, when and the reason)
Have you ever had any thoughts of suicide?
Yes
No
Have you ever made a suicide attempt?
Yes
No
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?
Yes
No
Have you ever had so much energy that you didn’t need to sleep, and made big plans or bad decisions?
Yes
No
Have you ever been so anxious that you couldn’t do anything, or even leave the house?
Yes
No
Do you often feel that you need to count, check or clean things in a special way?
Yes
No
Do you ever have several minutes of extreme anxiety and fear that comes out of the blue?
Yes
No
Do you ever feel that you can’t control your thoughts or that people can read or control your mind?
Yes
No
Have you ever thought about someone so much that you followed them?
Yes
No
Do you have trouble sleeping?
Yes
No
Do you have any medical illnesses?
Yes
No
(If yes, please provide details of any questions you answered YES)
Allergies to any foods or medications?
Yes
No
(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
None
Coffee
Tea
Soda
# of cups/cans per day
Do you drink alcohol?
Yes
No
(If yes, what kind?)
How many drinks per week?
Are you concerned about the amount you drink?
Yes
No
Have you ever experienced blackouts?
Yes
No
Are you prone to ”binge” drinking?
Yes
No
Have you received treatment for drug or alcohol addiction?
Yes
No
Do you use tobacco?
Yes
No
Cigarettes #/day
other
# of years, or year quit
Do you currently use recreational or street drugs?
Yes
No
(If yes, what kind?)
Cocaine
Heroin
Ecstasy
PCP
Amphetamine
Marijuana
GHB
LSD
Bath 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?
Yes
No
(If yes, please explain)
SOCIAL HISTORY
Where were you born and raised?
Did you develop normally as a child? (physically and mentally)
Yes
No
Did you have any problems in school? (discipline or behavioral)
Yes
No
Please check any of the following that applied to your childhood (please describe below)
Hyperactivity
Unhappy childhood
Happy childhood
Conduct problems
Learning difficulties
Head injury
Night terrors
Fears/worries
Stammering
Abuse
physical
emotional,
sexual
Interests and hobbies
Work History
Relationship History
Sexual Orientation
LEGAL HISTORY
Have you ever been arrested?
Yes
No
(If yes, please describe.)
Submit
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