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1 Les Fehmi, Ph.D. 317 Mt. Lucas Road Princeton NJ Fax: Date: Interviewer: Referred By: 1. NAME: MALE/FEMALE BIRTH DATE: / / 2. ADDRESS: 3. PHONE: (HOME) (CELL) (OFFICE) MARITAL STATUS: YEARS MARRIED: 6. * EMERGENCY CONTACT: NAME: PHONE: RELATIONSHIP: ADDRESS: 7. HOBBIES: (HOW DO YOU SPEND YOUR FREE TIME?) 8. PHYSICAL EXERCISE: (AMOUNT/TYPE AND FREQUENCY)
2 2 Do you have any of these common symptoms? Please note their intensity and frequency. Please include all symptoms, even if you consider them unimportant. Range: From none (0) to overwhelming (10)- (ex.,3-7) Frequency: Times a Day (D), Week (W), Month (M), Year (Y), ex., (3xD) PHYSICAL SYMPTOM COLD HANDS/FEET HEADACHES NECK, SHOULDER, BACK OR OTHER MUSCLE PAIN PAINS/TIGHTNESS IN CHEST OR HEART SWEATING HANDS/FEET, ETC. HIGH/LOW BLOOD PRESSURE NAUSEA, VOMITING, UPSET STOMACH DIARRHEA, CONSTIPATION HEART POUNDING, RACING, ARRHYTHMIAS MUSCLE TWITCHING OR TREMORS NERVOUSNESS, SHAKINESS EASILY FATIGUED, LOW ENERGY, BURNOUT DIZZINESS, VERTIGO OR FAINTNESS BODY NUMBNESS OR TINGLING EATING DISORDERS, LOSS OR INCREASE IN APPETITE RANGE OF INTENSITY FREQUENCY OTHER PAIN 2
3 BEHAVIORAL/EXPERIENTIAL SYMPTOM HAVING TROUBLE FALLING/STAYING ASLEEP UNABLE TO GET RID OF NEGATIVE THOUGHTS/IDEAS UNUSUAL BODY FEELINGS ANXIETY, FEAR, APPREHENSION, PANIC FEELING CRITICAL OF OTHERS NIGHTMARES STUTTERING, STAMMERING, ETC. TROUBLE REMEMBERING THINGS, MIND GOES BLANK FEELING EASILY ANNOYED, ANGERED, IRRITATED FEELING CONFUSED CRYING EASILY TEMPER OUTBURSTS YOU CANNOT CONTROL BLAMING YOURSELF FOR THINGS IMPULSIVE BEHAVIOR, EMOTIONAL INSTABILITY FIDGETY, RESTLESS, ANTSY, IMPATIENT FEELING LONLEY, SEPARATE, SAD SUBSTANCE ABUSE FOOD, ALCOHOL, DRUGS FEELING NO INTEREST IN THINGS FEELING GUILTY, SHAME WANTING TO BE ALONE TROUBLE CONCENTRATING, DISTRACTED MOOD SWINGS FEELING HOPELESS ABOUT THE FUTURE DEPRESSION, WITHDRAWL, PROCRASTINATION FEELING SELF CONSCIOUS TALKING TOO MUCH FEELING SOMETHING IS WRONG WITH YOUR MIND FEELING PEOPLE ARE UNFRIENDLY OR DISLIKE YOU LACK OF MOTIVATION, INTEREST SEXUAL SHYNESS RANGE OF INTENSITY FREQUENCY 3 3
4 MEDICAL / PSYCHOLOGICAL 4 1. PRIMARY SYMPTOM(S) COMPLAINT(S) FOR WHICH TREATMENT IS DESIRED DATE AND CONDITION SURROUNDING FIRST APPEARANCE OF EACH SYMPTOM WHO DIAGNOSED SYMPTOMS (NAME & ADDRESS) WHAT WAS DIAGNOSIS WHEN WAS IT DIAGNOSED 4. LAST PHYSICAL EXAMINATION BY PHYSICIAN NAME OF PHYSICIAN DATE OUTCOME/RECOMMENDATIONS 5. CURRENT MEDICATIONS (PLEASE LIST ALL MEDICATIONS CURRENTLY USED: SYMPTOM BEING MEDICATION DOSAGE FREQUECY OF USE EFFECTIVNESS SIDE EFFECTS PRESCRIBING START TREATED PHYSICIAN DATE 4
5 5 6. PAST/CURRENT USE OF STIMULANTS AND SOCIAL DRUGS (CHECK AND DESCRIBE FREQUENCY) ALCOHOL CIGARETTES MARIJUANA COFFEE TEA OTHER SUBSTANCES 7. NUTRITIONAL HABITS (DESCRIPTION OF ONE DAY S MEALS) BREAKFAST MID-MORNING SNACK LUNCH MID-AFTERNOON SNACK DINNER EVENING SNACK USE OF STRESS FOODS DESCRIBE FREQUENCY SUGAR CANDY DESSERTS SALT CHOCOLATE SOFT DRINKS HOW OFTEN DO YOU EAT OUT? 8. DESCRIBE ANY OCCASIONS WHEN YOU HAVE LOST CONSCIOUSNESS OR FAINTED 9. MARITAL AND/OR FAMILY RELATIONSHOPS. WHAT ARE THE MAJOR STRESSORS IN YOUR FAMILY LIFE? FATHER MOTHER DO YOU LIKE YOUR JOB? SCHOOL? WHAT ARE THE MAJOR STRESSORS IN YOUR JOB? SCHOOL? HOW WOULD YOU DESCRIBE YOUR RELATIONSHIP WITH OTHERS (FRIENDS, EMPLOYERS, EMPLOYEES)? 10. HOW WELL CAN YOU RELAX WHEN YOU HAVE NO SPECIAL PROBLEMS? (RATE 1-10) 5
6 6 11. HOW WELL CAN YOU RELAX WHEN YOU NEED TO RELAX (RATE 1-10) 12. DO YOU DO ANYTHING SPECIFICALLY TO RELAX, I.E., HAVE YOU ANY KNOWLEDGE AND/OR EXPERIENCE WITH ANY OF THE SYSTEMATIC RELAXATION TECHNIQUES SUCH AS MEDITATION, YOGA, AUTOGENIC TRAINING, BIOFEEDBACK TRAINING, ETC.? 13. WHAT DO YOU DO ON A DAILY BASIS TO SPECIFICALLY RELAX? WHEN DO YOU DO THIS AND HOW MUCH TIME DO YOU SPEND? TO BE FILLED OUT BY THERAPIST ONLY MEDICAL/PSYCHOLOGICAL 1. WHAT EMOTIONAL FEELING IS DOMINANT WHEN THE SYMPTOM IS PRESENT OR MOST INTENSE? (NERVOUSNESS, WORRY, FEAR, ANGER, FRUSTRATION, OTHER) 2. DO YOU HAVE ANY WARNING THAT THE SYMPTOM IS COMING ON OR WILL INCREASE IN INTENSITY (FEELING NERVOUS, DEPRESSED, MUSCLE TENSION, OR OTHER MENTAL OR EMOTIONAL STATE) 3. WHAT REDUCES OR ALLEVIATES EACH SYMPTOM? (ACTIVITY, MEDICATION, FOOD, BEVERAGES, RELAXATION, SLEEP, ETC.) 4. WHAT INCREASES THE SEVERITY OF EACH SYMPTOM (FOODS, STRESSFUL SITUATION, ACTIVITY, MEDICATION) 5. HAVE YOU NOTICED ANY TIME PATTERNS IN RELATION TO THE OCCURANCE OF YOUR SYMPTOMS? (TIME OF DAY/WEEK/MONTH, SLEEPING VS. WAKING, SEASON CHANGE, WEATHER ETC.) 6. HAVE YOU NOTICED THAT CERTAIN FEELINGS OR SITUATIONS MAY BE ASSOCIATED WITH THE ONSET OF SYMPTOMS? (STRESSFUL EVENTS, IMPENDING SOCIAL/ FAMILIAL/OCCUPATIONAL ENGAGEMENTS) 6
7 7. HOW ARE DAILY ACTIVITES LIMITED BEFORE/DURING/FOLLOWING THE APPEARANCE OF EACH SYMPTOM? 7 8. HOW WOULD YOUR LIFE BE DIFFERENT WITHOUT YOUR SYMPTOM (S)? 9. WHAT, IF ANY, BENEFITS DO YOU RECEIVE FROM YOUR SYMPTOMS (E.G. ATTENTION FROM OTHERS, OPPORTUNITY TO TAKE IT EASY, DISTRACTION FROM PERSONAL PROBLEMS)? 10. DETAILED DESCRIPTION OF SYMPTOM(S) COMPLAINT (S) FOR WHICH BIOFEEDBACK TRAINING IS DESIRED. FOR EACH SYMPTOM: SYMPTOM LOCATION QUALITY OF PAIN INTENSITY DURATION FREQUENCY 11. DO YOU EXPERIENCE SUICIDAL THOUHTS? HAVE YOU EVER ATTEMPTED SUICIDE? DO YOU THINK YOU MIGHT EVER ATTEMPT SUICIDE? 7
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