Patient Questionnaire. Name: Date: A. What are the main concerns or problems that brought you here today?
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1 Patient Questionnaire Name: Date: D.O.B.: Age: Referred By: Presenting Problem A. What are the main concerns or problems that brought you here today? B. Problem Checklist: please circle all that apply: 1. Abuse - physical, sexual, emotional 2. Aggression, violence 3. Alcohol use 4. Anger, hostility, arguing, interpersonal conflicts 5. Anxiety, nervousness, tension, panic attacks 6. Attention, concentration, distractibility 7. Children, child care, parenting 8. Compulsions, Obsessions 9. Decision making, indecisiveness 10. Delusions 11. Depression, low mood, sadness, crying 12. Divorce 13.Drug use - legal, illegal 14. Eating problems - overeating, undereating, appetite changes 15.Employment issues 16. Failure 17. Fatigue, low energy 18. Fears, phobias 19. Financial troubles 20. Gambling 21. Grief, mourning, death, loss 22. Guilt 23. Health, illness, physical concerns 24. Impulsiveness, irresponsibility 25. Judgment problems, risk taking
2 2 26. Legal trouble 27. Loneliness 28. Marital conflict 29. Memory problems 30. Mood swings 31. Perfectionism 32. Relationship problems 33. Self esteem 34. Sexual issues 35. Sleep problems - too much, too little, insomnia 36. Smoking/ tobacco use 37. Stress, relaxation, stress management 38. Suicidal thoughts 39. Weight/diet issues 40. Withdrawal, isolation Family History A. Your parents relationship with each other: B. Your relationship with your biological mother: C. Your relationship with your biological father: D. How many step-mothers did you have? How many step-fathers? E. Brothers/Sisters (Names and ages and something about each):
3 3 F. Were you ever in any residential placements, institutional placements, or foster care? Yes No Abuse History (as a child or adult) I was not abused I was abused. If you were abused, please indicate the kind of abuse. P = physical; S = sexual such as touching, molest, intercourse; E = emotional, i.e., humiliation; V = verbal; N = neglect such as failure to feed, shelter, protect. Kind of abuse Education and Training A. Current School/Grade? Were you ever suspended from school? No Yes B. Are you having any difficulties in school: Medical History A. Please list all hospitalizations and operations: Age Illness/Diagnosis B. List all medications taken within the last year (prescription, over-the-counter) Medication Dose Taken for what reason
4 4 C. Name and specialty of physicians who have treated you in the last 5 years: Name Specialty D. Have you ever suffered from any of the following: Allergies Cancer Diabetes High blood pressure Thyroid trouble Ulcers Other: E. Is your diet unusual in any way? No Yes, please explain: F. What kinds of physical exercise do you get? How often? G. How much caffeine do you consume daily? (coffee, soda, tea) Family Medical History A. Father s health: good fair poor B. If deceased, age and cause of death: C. Mother s health: good fair poor D. If deceased, age and cause of death:
5 5 Chemical Use A. Do you smoke anything? What? How much? How often? B. Would you say you are a: social drinker heavy drinker alcoholic If you drink, how much? How often? C. Have you ever felt the need to cut down on your drinking? Yes No D. Have you ever felt guilty about your drinking? Yes No E. Would you say you don t use drugs are a recreational drug user are an addict have a drug problem F. How would you describe your drug use? I. Chemical Last Used Psychiatric History A. Have you ever received psychological or psychiatric counseling services before? No Yes, please explain: B. Have you ever taken medications for psychiatric or emotional problems? No Yes, please indicate what and when taken:
6 6 C. Have you ever been hospitalized for an emotional problem? No Yes, please explain: D. Have you ever made a suicide attempt? No Yes, please explain When and how: E. Have any close relatives been treated for psychiatric problems? If yes, please specify: F. Has any close relative committed suicide? No Yes, please explain: Legal History Have you ever been charged with or convicted of a crime? No Yes, please explain:
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1 Client Name: Age: DOB: Today s Date Address: City: State: Zip: Home Phone: ( ) Ok to leave message? YES NO Work Phone: ( ) Ok to leave message? YES NO Current Employer (or school if a student): Gender:
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COUPLE COUNSELING ASSESSMENT
COUPLE COUNSELING ASSESSMENT Date: Client 1 information: Name: Gender: Male Female Age - Date of Birth: Driver s License #: Email: Preferred Please Circle: Self-Pay or Insurance Client 2 information: Name:
SYMPTOM QUESTIONNAIRE (please check any of the following symptoms you have)
SYMPTOM QUESTIONNAIRE (please check any of the following symptoms you have) Please also provide a value from 1-10 describing the intensity of each symptom (10=very severe, 1=very minor) Anger management
NANCY IREY HOLMES, PSY D Licensed Psychologist
1. IDENTIFYING INFORMATION NANCY IREY HOLMES, PSY D Licensed Psychologist Portland: (503) 235-2466 Redmond: (541) 330-4428 www.nancyholmespsyd.com CLIENT INFORMATION Name: Date: Address: City, State, Zip:
PHONE: RELATIONSHIP: ADDRESS:
Les Fehmi, Ph.D. 317 Mt. Lucas Road Princeton NJ 08540 609.924.0782 Fax: 609.924.0782 lesfehmi@openfocus.com www.openfocus.com Date: Interviewer: Referred By: 1. NAME: MALE/FEMALE BIRTH DATE: / / 2. ADDRESS:
CereScan Corp, Littleton, Colorado 2014 All rights reserved.
PATIENT: EXAM: Quantitative Single Photon Emission Computed Tomography (qspect) Name: If female: Are you nursing or pregnant? Yes No MR #: Handed: DOB: Date: Age: Intake Physician: Hilary Sparrow, MA,
CBT Intake Form. Patient Name: Preferred Name: Last. First. Best contact phone number: address: Address:
Patient Information CBT Intake Form Patient Name: Preferred Name: Last Date of Birth: _// Age: _ First MM DD YYYY Gender: Best contact phone number: Email address: _ Address: _ Primary Care Physician: