1811 B Green Circle Valdosta, GA Do you have any problems at this time?
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1 TVC 1811 B Green Circle Valdosta, GA Name: Date: Do you have any problems at this time? Please check any symptoms that describe how you feel, think, or behave currently or during the past few weeks: ( ) Abdominal pain ( ) Aggressive/abusive towards others ( ) Agitation ( ) Attempts to harm self ( ) Avoidance of public places ( ) Back pain ( ) Change in ability to walk ( ) Chest pain ( ) Chest tightness ( ) Chronic sadness ( ) Confused/worried about sexual behavior ( ) Constipation ( ) Crying episodes ( ) Diarrhea ( ) Difficulty at work ( ) Difficulty completing tasks ( ) Difficulty concentrating ( ) Difficulty focusing ( ) Difficulty functioning socially ( ) Difficulty making decisions ( ) Difficulty waiting your turn ( ) Dizziness ( ) Easily startled ( ) Excessive gambling ( ) Excessive spending ( ) Excessive worry ( ) Fainting ( ) Fear of dying ( ) Fear of leaving home ( ) Fear of loss of control ( ) Fearfulness ( ) Frequent forgetfulness ( ) Frustration ( ) Hard to stay with job very long ( ) Hopelessness ( ) Intrusive thoughts of bad memories ( ) Irritability ( ) Legal problems ( ) Loss of appetite ( ) Low energy/fatigue ( ) Marital conflict ( ) Memory problems ( ) Multiple sexual partners ( ) Muscle stiffness ( ) Muscle weakness ( ) Nausea/vomiting ( ) Neck pain ( ) Nightmares
2 ( ) Not well organized ( ) Overeating ( ) Panic attacks ( ) Physical abuse ( ) Pounding heart/palpitations ( ) Problems with co-workers ( ) Racing thoughts ( ) Reduced interest in activities ( ) Re-living bad experiences ( ) Restlessness ( ) School problems ( ) Seeing things others don t ( ) Seizures ( ) Sexual abuse ( ) Shortness of breath ( ) Sleep problems ( ) Snoring ( ) Staying up for days without sleep ( ) Taking on too many tasks ( ) Tendency to act impulsively ( ) Thoughts of physically hurting others ( ) Thoughts of suicide ( ) Trembling/shaking ( ) Vision changes ( ) Withdraw from others Please describe why you are seeking help at this time Has any member of your family been hospitalized for mental health concerns? If yes, please list who, when and for what reason: Do/did you have any family members who have/had problems with drinking alcohol or using drugs? If yes, please list who, when and if it is still a problem: Has any member of your family attempted/committed suicide? If yes, please list who, when, and what happened: What is your best memory about your family when growing up?
3 If you could change anything about your family situation right now, what would it be? Have you ever seen a counselor, psychologist, psychiatrist, or other mental health professional for any mental health or drug/alcohol concerns? If yes, please list who, when and why: Have you ever been hospitalized for mental health or drug/alcohol concerns? If yes, please list when and for what reason: Do you have thoughts of harming yourself? If so, how often does this happen? Have you ever tried to harm yourself? If so, when did this happen? Did you receive medical help at the time? Current Medications (Please include prescription, over the counter, herbs, vitamins, and other remedies) Medication Dosage/when taken Reason taking Prescribing Doctor
4 Allergies to medications: Please list any current medical problems or concerns: Please list any past serious illnesses, surgeries or health concerns: Exercise and Physical Recreational Activity Type of activity How often Would describe yourself as physically active? Do you currently have a primary care physician? If so, please list his/her name: Are you currently under the care of any other physicians? If so, please list names:
5 Use of substances (on average) If none, please leave blank. Alcohol Tobacco Current amount glasses per day glasses per week cigarettes per day cigars per day smokeless cans per day Most used in past glasses per day glasses per week cigarettes per day cigars per day smokeless cans per day Caffeine (tea, coffee, soda) servings per day servings per day Marijuana Cocaine Diet pills Name: per day per week times per day times per week pills/doses per day pills/doses per week per day per week times per day times per week pills/doses per day pills/doses per week Marital status: Children: Education: Living arrangements: Employment: Military service:
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Demographic Information Form PATIENT INFORMATION Male Female Other / / (Patient Legal Last Name) (Patient Legal First Name) (MI) (DOB) Mailing: SSN#: - - Home Cell Relationship Status (circle one): Single
Counseling Service Personal Information Form. Name: Preferred Name: Can your preferred name be updated for all LC Health and Wellness offices?
Date: Counseling Service Personal Information Form Name: Preferred Name: Can your preferred name be updated for all LC Health and Wellness offices? Yes No Phone number: May the Counseling Service leave