PRESENTING CONCERNS & HISTORY SYMPTOMS
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1 PRESENTING CONCERNS & HISTORY Name: Date: Your main concerns: What got you to actually pick up the phone and call: Rate every symptom below that you have ever significantly experienced: 1 = mild intensity, 2 = moderate, 3 = severe. Circle the number if you have had the symptom anytime during the past two months. Some items are repeated; mark them each time. Depression: depressed mood lessened interest in normal activities 5% weight loss or gain in one month inability to sleep sleeping too much excessive fatigue feelings of worthlessness unrealistic guilt thoughts of death suicidal thoughts, plan, or attempt appetite too high appetite too low low self-esteem poor concentration unable to make decisions feelings of hopelessness crying spells Elevated Mood: inflated self-esteem decreased need for sleep talkative mind races from one idea to next distractible exaggerated level of activity: social, work, school physical restlessness excessive spending accelerated sexual behavior risky financial investments SYMPTOMS Anxiety: panic attacks phobias obsessions--thoughts you can t stop thinking compulsions--behaviors you can t stop doing doubting and indecisions dry mouth sweating wringing hands dizziness choking nausea numbness chest pain fear of dying fear of going crazy/out of control fear of leaving the house Trauma Stress: recurring or intrusive memories of a trauma recurring dreams or nightmares sudden acting/feeling as if trauma is recurring distress at events that symbolize or resemble trauma you avoid thoughts or feelings that remind you of trauma you avoid activities or situations that remind you of trauma inability to recall important aspects of trauma diminished interest in significant activities feelings of detachment or disconnectedness from environment narrow range of emotions 4/1/08 - Page 1
2 sense of foreshortened future (e.g., feel will die early) difficulty falling or staying asleep irritability or outbursts of anger difficulty concentrating excessively watchful for danger exaggerated response when surprised by another person physiological reaction at events that remind of trauma ADHD Inattention: poor attention to details; careless mistakes poor attention in tasks or play poor attention when spoken to directly poor follow through on instructions failure to finish schoolwork, chores, or duties (not oppositional behavior or failure to understand instructions) difficulty organizing avoiding or disliking sustained mental effort losing things needed for activities easily distracted forgetful Hyperactivity: fidgeting, squirming (or did so when a child) leaving seat or desk often feelings of restlessness difficulty engaging in leisure quietly "on the go" or "driven by a motor" talking excessively Impulsivity: blurting out answers before questions are completed difficulty awaiting turn interrupting/intruding on others Mood-Related Stress: volatile, intense relationships potentially self-damaging impulsiveness (spending, sex, substance abuse) mood swings intense anger thoughts of wanting to hurt someone; homicidal thoughts self-mutilating behavior identity disturbance feelings of emptiness/boredom difficulty being alone frantic efforts to avoid abandonment Thinking Processes: memory impairment difficulties with any of five senses problems planning events or carrying out complicated mental tasks outbursts of temper; emotions that go way up and down quickly head injury identifiable brain disease Relationships: divorce arguments jealousy anger fights over money/sex can t establish a relationship emotionally dependent relationships simultaneous mutliple relationships Eating: binge eating purging (forced vomiting) bulimia anorexia obesity eating to medicate away feelings Drugs, Alcohol, Other Compulsive Behaviors: Describe your pattern of behavior for each item, the time frame involved, and your current experience. alcohol cocaine crystal meth other amphetamines heroin nicotine ecstasy PCP LSD marijuana other drugs: gambling overworking; no personal life compulsive buying or shopping other compulsive behaviors (counting things, checking locks, etc.) obsessive thoughts 4/1/08 - Page 2
3 Sexually Compulsive Behavior: more extensive sexual behavior than intended desire & unsuccessful efforts to stop, reduce, or control sexual behavior inordinate time spent obtaining sex, being sexual, or recovering from sex preoccupation with sexual behavior or preparatory activities for sex replaces occupational, academic, domestic, or social obligations continuation despite negative consequences needing more and more sex, or more intense sex, over time avoiding making social, occupational, or recreational plans to be available for possible sex distress, restlessness, irritability if unable to be sexual Sexually Anorexic Behavior: feeling resistant or aversive to sexual activity mental preoccupation and obsession with avoiding sexual contact aversion to sex even if self-destructive or harmful to relationship extreme efforts to avoid sexual contact avoiding intimacy and relationships out of fear of sexual contact self-mutilation, distortions of body appearance, dressing in an unattractive manner to avoid being sexually attractive rigid, judgmental attitudes towards own sexuality and sexuality of others extreme shame and self-loathing about sexual experiences, body perceptions, and sexual attributes distress, anxiety, restlessness, or irritability because of sexual contact or potential contact despair about sexual functioning affects work, hobbies, friends, family, and primary relationship Codependency: seeking validation through being needed and by rescuing others strong feelings of vulnerability related to abandonment attraction to individuals who need parenting getting into relationships with individuals who have an addiction remaining in a relationship even when clearly unsatisfactory trying to control another person s destructive behaviors being possessive of another person Other: feelings of unreality about yourself or environment loneliness lack of identity feelings of helplessness marital difficulties parenting difficulties employment/school problems compulsive under-earning; can accept only low paying jobs money management problems perfectionism spiritual or religious concerns hyperreligiosity losses, deaths frequent lying lack of assertiveness sexual performance problems; impotence sexual orientation concerns gender identity concerns shy, uneasy with others, withdrawn concerns about living arrangements aggressive or violent behavior generalized dissatisfaction headaches, abdominal distress other: (list) 4/1/08 - Page 3
4 PERSONAL HISTORY Please give details for the following: Psychiatric History Inpatient psychiatric hospitalization (including drug or alcohol rehab): Outpatient treatment: (starting when, by whom, how long, helpfulness) Diagnosis: (when, by whom) Current psychiatric medications (name and phone number of psychiatrist, names and amounts of medications, when started each): Circle 12-step meetings attending or attended: AA NA AlAnon Coda SA SLAA SCA SAA DA OA Do you have a sponsor? Y N What step are you working on? Current suicidal thoughts or plans: (include family history of suicide, current reasons for being suicidal, means you would use, and what could happen that might push you over the edge) Previous suicidal thoughts, plans, or attempts: Thoughts of hurting someone else (even for their own good ); current or past homicidal thoughts, actions, plans: Developmental History Birth and infancy: Difficulties during your mother s pregnancy with you; date and place of birth: Congenital or hereditary defects: Infancy: (problems nursing, weaning, developmental milestones such as walking or talking, diseases) Before age 6: (problems with sleeping, eating, familiar relationships; early recollections or outstanding memories, traumas not mentioned above) 4/1/08 - Page 4
5 Primary school years: (problems with social development, school attendance, feelings about school, family happenings, family moves) Adolescent development: (problems during junior high and high school, dating, friendships, social activities, early sexual knowledge and experiences, positive things you accomplished) Family of Origin Mother: Age (if living): Year deceased: Age at death: Your relationship: Her marital history: Father: Age (if living): Year deceased: Age at death: Your relationship: His marital history: Step parents: (age, deceased, description, relationship, who you lived with) Siblings: # younger siblings # older siblings Significant sibling relationships: Atmosphere in home: (including how punished, physical environment, who was in home) Parents: (circle) rigid/authoritarian disengaged/cold chaotic enmeshed alcoholic sadistic Abuse inside or outside home: sexual physical emotional Specific role in family (if you had one and know it): hero scapegoat lost child clown Other family: (extended family, mental illness history of family including alcoholism, people outside your family who were an emotional resource to you) Academic History and Early Adulthood College attendance: (where, when, major, grade point average) Significant happenings, both positive and negative, during early adulthood: 4/1/08 - Page 5
6 Marriages, Partnerships, Current Relationships, Living Situation Marriages/significant partnerships: (past and present) Children: (ages, significant concerns) Psychiatric history of spouse and children: Current living situation: Other significant relationships: Medical History Height: Significant past illnesses: Weight: Current illnesses: (any medications prescribed, when started) Current physicians: (phone numbers, what they are treating you for) Work History Current and past employment: (any significant information) Legal History Legal problems, arrests, etc.: Middle/Older Adulthood & Any Other Relevant Information Significant happenings, both positive and negative; any trauma not covered elsewhere: 4/1/08 - Page 6
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