GeMS Young Adult Self-Report Questionnaire
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- Blaise Watson
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1 Patient Name: D.O.B: MRN: GeMS Young Adult Self-Report Questionnaire This form will help us learn about you prior to your appointment in GeMS. It asks about your gender identity experience, mental health, medical and school experiences, as well as the health of close family members. Please fax self-report and patient questionnaire to FAX , Attention: GeMS Or to Please fill out as much as you can. It is fine to leave questions blank. Today s Date / / Chosen or Affirmed Name Legal Name Pronouns Date of Birth / / Signature Please print your name 1
2 Current gender identity Current gender presentation and expression Current stressors (school, moving homes, divorce, new job, language barrier, etc.) Past stressors: Current support systems (family, school, significant other, job, therapist, etc.) Your positive qualities, talents and skills: What is your cultural, ethnic and religious background? When did you first begin exploring your gender identity? What do you do for fun? 2
3 BIRTH HISTORY and FAMILY HISTORY During pregnancy, did your mother: Yes No Get sick/have an accident? Describe Yes No Take any medication? Describe Yes No Have depression/stress? Describe Yes No Smoke? How much? Yes No Use alcohol or drugs? How much? Were you born: On time Early..how early? Late how late? Birth weight Did you have any medical problems at birth? If yes, please describe them briefly. You will be able to give your clinician more details about all of these things at your appointment. Number of people in your household? Who lives with you? Please list here: Name/Age Gender Relationship To you Primary Language WORK AND SCHOOL Are you currently working, in school or both? If working, what is your occupation? If you are in school, please answer questions below: School Name School Phone (HS) Grade in School Significant teacher or guidance counselor: 3
4 Is your school aware or your gender exploration? Do you feel supported in your school? Please describe: Have you ever received special education services? Yes No Have you ever repeated a grade? Yes No If yes, which grade? Have you ever been bullied at school? Yes No Not sure What is your experience with the following? Schoolwork Good Average Poor Homework Good Average Poor In-school behavior Good Average Poor Friendships Good Average Poor Attendance Good Average Poor MENTAL HEALTH Are you currently in therapy? Please complete the following: Mental health clinicians, past and current Name Type (psychiatrist, psychologist, social worker, etc.) Phone Number Currently seeing this clinician? Yes Yes Yes No No No 4
5 Current medications, OR bring in list/medications Name of medication Dose Reason for taking How long was it taken for? Helpful? (Yes or Reason for stopping if no longer taking Have you ever been psychiatrically hospitalized? Facilities and dates: Reason(s) for hospitalization(s): Please complete the checklist below for family psychiatric and medical history. If you aren t sure about any of these items, feel free to leave them blank and ask your clinician for help. YOU Your Mother Your Father Your Sibling Relatives (aunt, uncle, grandparent) Anxiety Attention Deficit Hyperactivity Disorder (ADD, ADHD) Autism Spectrum Disorder Bipolar Disorder (Manic Depression) Depression Developmental Delay Eating Disorder 5
6 Intellectual Disability Learning Disability Obsessive/Compulsive Abuse/neglect Conduct Problems Hearing Voices/Seeing Things Self-Harm, any kind Sleep Problems Substance Use/Dependence Suicide Attempt Suicidal Thoughts Toileting Problems Trauma Symptoms Unexplained physical symptom Psychiatric Treatment Psychiatric Hospitalization Medical Problems/Procedures Please provide brief details for the boxes you checked or tell us about any problem that was not listed. You will be able to discuss these concerns at your first appointment. Please detail any chronic or significant medical conditions in your past and/or for which you are currently receiving care 6
7 Is there anyone else who has been helpful with your gender exploration? (PCP? School advisor? Clergy? Etc.) Please feel free to add any other information you would like us to know before your first appointment. We look forward to meeting with you. 7
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Adult Patient Information Name:, Sex:, Age: Ethnicity, Race Date of Birth:, Email address: Address:, City: State:, County,, Zip: Telephone numbers: Home: ( ),Work: ( ) Cell: ( ) Referral by: Person to
I also hereby give permission to any of the above to share information with Crown Colony Pediatrics about my child.
Crown Colony Pediatrics Barbara E. Angus, M.D. 500 Congress Street, Suite 1F Beata J. Brzozowska, M.D. Quincy, MA 02169 Lisa B. Corkins, M.D. Phone: (617) 471-3411 Fax: (617) 471-3584 Lisa R. Natkin, M.D.
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A New Tomorrow Behavioral Health Services
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