CHECKLIST OF CONCERNS AND HISTORY FORM
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- Lionel Fleming
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1 CHECKLIST OF CONCERNS AND HISTORY FORM Name: Date: Please mark any items that apply to you. PROBLEM AREAS--CAREER, SCHOOL Career concerns, goals, and choices Unemployment Job stress School problems Learning problems Work performance issues such as procrastination Work life balance issues (workaholism/overworking) Difficulty maintaining employment PROBLEM AREAS--RELATIONSHIPS Communication problems Dating issues Detachment or estrangement from others Divorce, separation Friendships Feeling physically unsafe with my partner Infidelity, affairs Interpersonal conflicts Parenting issues Sexual issues with partner Social problems Physical fights with relationship partner Physical fights with others Relationship conflict Other Relationship problems (specify: ) Withdrawal, isolating PROBLEM AREAS--LIFE EVENTS Childhood issues (your own childhood) Financial or money troubles, debt, impulsive spending, low income Grieving, mourning, deaths, losses Legal matters, charges, suits Other (Please specify: ) PROBLEM AREAS--PHYSICAL WELL-BEING Headaches, neck or back pain (Please specify: ) Health, illness, medical concerns, physical problems Menstrual problems, PMS Pains, chronic (Please specify: ) Sexual functioning problem (e.g. erectile dysfunction, painful intercourse) Page 1 of 7
2 PROBLEM AREAS--SELF Identity issues Sexual identity issues Suicidal ideas Thoughts that life may not be worth living Self-esteem problems EMOTIONAL CONCERNS Alert for danger, even in safe locations Anger, hostility Distressing memories of the past Suspiciousness Anxiety, nervousness Agitated Fear of leaving my home Fear of specific locations, such as elevators or planes (Please specify: ) Fear of specific situations, such as heights or snakes (Please specify: ) Fear of social situations Fear of abandonment Obsessive thoughts Panic or anxiety attacks Feeling hyper or wound up Shyness Tension can t relax Attention, concentration Confusion Distractibility Memory problems Loneliness Depression, low mood, sadness, crying More depressed in the morning, with mood better later in the day More depressed in the winter, mood better in the summer Emptiness feelings Failure feelings Fatigue, tiredness, low energy Guilt Inferiority feelings Motivation problems Oversensitivity to rejection Oversensitivity to criticism Lack of interest in my usual activities Hopelessness Mood swings Overly high energy level for my age Perfectionism Sexual drive lack of Feeling that others are out to get me Feeling that others are watching me Hearing voices Page 2 of 7
3 BEHAVIORAL ISSUES I drink alcohol more than 2 nights per week At least one day a week, I have 4 drinks or more (if female) or 5 drinks or more (if male) I have used an illegal drug in the last month I smoke at least one cigarette per week At least once a week, I drink more than 2 cups of coffee, OR more than 4 colas or cups of tea I have had a DUI (When? ) I have been charged with a crime in the past (other than parking, speeding or DUI) Aggressive or violent thoughts or behaviors Arguing Compulsive behaviors (Please specify: ) Repetitive behaviors (e.g. hand washing, checking doors, checking stove) Cutting or otherwise injuring self Other self-harm in past (Describe: ) Decision making problems, indecision, mixed feelings, putting off decisions Disorganization Gambling Irritability Impulsiveness Irresponsibility Judgment problems, risk taking Self-neglect, poor self-care Suicide attempt in past (When? ) Temper problems, self-control, low frustration tolerance EATING/WEIGHT ISSUES Lack of appetite Weight loss (How much? Over what time? ) Overeating Weight gain (How much? Over what time? ) Vomiting Taking laxatives, enemas or diuretics to lose weight Bingeing on food Diet issues Fear of becoming fat SLEEP ISSUES Sleeping too much Insomnia Difficulty going back to sleep upon awakening during night Too much worrying or thinking keeps me from getting to sleep Waking at least 2 hours too early in the morning Feeling extremely restless or squirmy prior to bedtime I have taken a sleeping pill or drank alcohol to sleep at least once in the past month Nightmares or upsetting dreams Suddenly falling asleep in inappropriate locations Snoring Grinding teeth during sleep Stopping breathing briefly during sleep (noticed by you OR partner) Sleepwalking Page 3 of 7
4 ANY OTHER CONCERNS OR ISSUES THAT MAY BE A FOCUS FOR PSYCHOTHERAPY?: WHICH CONCERNS DO YOU MOST WANT HELP WITH? INFORMATION CHECKLIST Please review the following list of treatments you may have had in the past. Please put a check next to any that apply to you and indicate the dates, to the best of your recollection. Dates: Inpatient psychiatric hospitalization No Yes Intensive outpatient treatment No Yes (e.g. at least 2-3 days per week) Psychotherapy No Yes Outpatient Substance Abuse counseling No Yes Attending AA/NA/CA meetings No Yes Taking medication for emotional difficulty No Yes Taking medication for sleep No Yes PSYCHOTROPIC MEDICATIONS I do not take psychotropic medications Psychiatrist Phone Fax Address If you enter treatment with me for psychological problems, I strongly recommend that treatment be coordinated between your psychiatrist and me. Do you have any problems with this? No Yes Page 4 of 7
5 EDUCATION Did you graduate from HIGH SCHOOL? Yes Year of graduation No COLLEGE OR VOCATIONAL SCHOOL Attendance and Degrees/Certificates: From To School Degree Program Did you graduate? EMPLOYMENT for the last 5 years Dates From To Name of military or employers Job title or duties Reason for leaving HISTORY OF EVENTS Please indicate any of the following events that may have occurred to you in the past: My parents/caretakers punished me physically as a child or teenager My parents/caretakers were verbally harsh and critical of me as a child or teenager My parents/caretakers did not provide appropriate supervision, food, shelter or other protection. My parents/caretakers were unaware of my difficulties when I was a child or teenager. There was violence in my home growing up. I experienced inappropriate sexual contact as a child or teenager I experienced sexual harassment as an adult I experienced other upsetting sexual experience(s) as an adult As an adult, I experienced a physical injury intentionally caused by another adult. Someone has hit, kicked, punched or otherwise hurt me during the last 12 months. Someone has threatened me verbally with bodily harm. I experienced any other upsetting experience(s) as noted below: PRESENT RELATIONSHIP I do not have a partner at present How would you characterize your relationship with your partner? Page 5 of 7
6 USE OF CAFFEINE, ALCOHOL, TOBACCO AND STREET DRUGS How much coffee, cola, tea, or other sources of caffeine do you consume each day? ALCOHOL 1. Have you ever felt the need to cut down on your drinking? No Yes 2. Have you ever felt annoyed by criticism of your drinking? No Yes 3. Have you ever felt guilty about your drinking? No Yes 4. Have you ever taken a morning "eye-opener"? No Yes 5. How much beer, wine, or hard liquor do you consume each week, on the average? 6. How much TOBACCO do you smoke or chew each week? 7. Which STREET DRUGS have you used in the last 3 years? LEGAL ISSUES 1. Are you presently suing anyone or thinking of suing anyone? No Yes If yes, please explain: 2. Is your reason for coming to see me related to an accident or injury? No Yes If yes, please explain: 3. Are you required by a court, the police, or a probation/parole officer to have this appointment? No Yes If yes, please explain 4. Have you had any contacts with the police, courts, and jails/prisons regarding a crime that you were charged with? No Yes 5. Were you ever locked up in jail or prison--even if just overnight? No Yes 6. Are there any other legal involvements I should know about? No Yes If yes, please describe: MEDICAL HISTORY 1. Please list all CURRENT MEDICAL PROBLEMS that you have (Be sure to include chronic conditions such as asthma, seizure disorder, arthritis, diabetes, etc.). 2. Please rate your current level of PHYSICAL PAIN on a scale of 0-10, with 0 being no pain and 10 being the worse pain you have ever had Rate the most severe pain you have had in the past month Why were you experiencing pain? Page 6 of 7
7 3. List all MEDICATIONS, HERBAL SUPPLEMENTS, VITAMINS, AND OVER-THE-COUNTER DRUGS you have taken in the last month. Medication/drug Dose (how much?) Taken for Prescribed by 4. Have you had any SURGERIES, including any plastic surgery? If so, please list briefly: 5. Have you ever been hit or injured on the HEAD? No Yes Have you ever been knocked UNCONSCIOUS? No Yes Please describe: HEALTH HABITS 1. What kinds of physical exercise do you get? 2. How many times per week do you typically exercise for 20 minutes or more? 3. Do you try to restrict your eating in any way? How? Why? 4. Do you have any problems getting enough sleep? 5. What is your average number of hours of sleep per night? Page 7 of 7
Client Intake Form. First Name: M.I.: Last Name: Birthdate: Gender: Age: Address: City: State: Zip:
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Patient Questionnaire. Name: Date: A. What are the main concerns or problems that brought you here today?
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Psychiatry. Name: address: Best phone number to reach you: Best times to reach you: Who referred you to the clinic today?
Email address: Best phone number to reach you: Best times to reach you: Who referred you to the clinic today? What is your reason(s) for seeking help at this time? How long have you felt this way? Have
Client Intake Form. Briefly describe the reason(s) you are seeking psychotherapy at this time:
Client Intake Form Thank you for taking the time to openly and honestly answer the questions below. Your genuine responses are appreciated, as all information provided will assist your therapist to better
Child & Adolescent Life History Questionnaire. Moving Forward Counseling, LLC Middlebelt Road, Suite 100-C Farmington Hills, MI 48334
Child & Adolescent Life History Questionnaire Moving Forward Counseling, LLC 32813 Middlebelt Road, Suite 100-C Farmington Hills, MI 48334 Please answer these questions to the best of your ability so that
General Information. Name Age Date of Birth. Address Apt. # City State Zip. Home Phone Work Phone. Social Security Number Marital Status
Accredited Member Center of The American Academy of Sleep Medicine 400 Riverside Drive, Suite 1500, Bourbonnais, IL 60914 Phone (815) 933-2874 Fax (815) 939-9413 www.riversidemc.net/sleep General Information
Demographic Information Form
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
ADULT PATIENT AND FAMILY INFORMATION FORM
Psychiatry and Behavioral Health at ADULT PATIENT AND FAMILY INFORMATION FORM IDENTIFYING INFORMATION Date Completed: Name: Cell Phone: Date of Birth: Gender: Work Phone: Home Phone: Employer: Marital
Full Circle Psychotherapy: Ayla Marie Carter, MA, LMHC
Full Circle Psychotherapy: Ayla Marie Carter, MA, LMHC aylacarter@fullcirclepsychotherapy.org www.fullcirclepsychotherapy.org (253) 686-4681 Name (First, Middle, last): Birthdate: Age: Gender: Sexual Orientation:
CLIENT QUESTIONNAIRE. Preferred Name: Address: (Street) (City/State) (Zip Code) Home Phone: Cell Phone: Relationship: Cell Phone:
CLIENT QUESTIONNAIRE Full Legal Name: DOB: / / Preferred Name: Email: Address: (Street) (City/State) (Zip Code) Home Phone: Cell Phone: Can we leave voice messages for you at these numbers? Yes Text Messages?
SANDSTONE PSYCHOLOGICAL PRACTICE
SANDSTONE PSYCHOLOGICAL PRACTICE Christina L. Aranda, Ph.D. & Janell M. Mihelic, Ph.D. CONTACT INFORMATION New Client Questionnaire Name: Date: Date of Birth: Age: _ Address: Preferred Phone Number: Type:
Pediatric Sleep History
Fax 423-431-2983 Pediatric Sleep History Patient/ Child s Name: Date of Birth: Parent Name: Last 4 of Social Security No: Gender: Male Female Height: Weight: Age: Race: Street Address: City: State: Zip:
LIBERTY SLEEP ASSOCIATES, LLC SLEEP DISORDERS CENTER
SLEEP QUESTIONNAIRE Patient Name: Sex: Age: Date: Occupation: Usual Work Hours/Days: Family Physician (PCP): Ht Wt Neck Size: What was your weight one year ago? Five years ago? Marital status: (circle
Adolescent Symptom Inventory-4 Parent Checklist 12 Years and Over Please return checklist to the office prior to your appointment
Adolescent Symptom Inventory-4 Parent Checklist 12 Years and Over Please return checklist to the office prior to your appointment Youth s Name Date of Birth Age Name of Person Completing Form Father s
AT RISK YOUTH ASSESSMENT YAR application/assessment must be reviewed with YAR coordinator prior to being filed
Court Services At-Risk Youth Drug/Alcohol Services Probation Drug Court Diversion Detention CASA Truancy CLALLAM COUNTY JUVENILE & FAMILY SERVICES Peter A. Peterson Director 1912 West 18th Street Port
Client Name: Age: DOB: Date: What brings you to therapy?: How long has the problem been present?
Hope in Healing Counseling and Wellness, LLC Stacy Nunne, MA, LMFT, SEP, RN 600 West 78th Street, Suites 10A-C Mailing Address: PO Box 892 Chanhassen, MN 55317 Chanhassen, MN 55317 Phone: 952-215-5208
Child s name: Nickname: Date of Birth: / / Sex: Male Female SSN: Today s date: / / Parent s Name #1: Home phone: ( ) Cell: ( )
Please fill out the entire form, answering the questions as they pertain to your child or teen. Leave blank any that are unclear or that you want additional clarification on. Thank you. General Information:
Restore Counseling Center 630 E Southlake Blvd, Ste 127, Southlake, Tx
Adult Information Restore Counseling Center 630 E Southlake Blvd, Ste 127, Southlake, Tx 76092 817-614-1488 Dx code: Welcome to Restore Counseling Center. In order for us to gain a better understand of
130 Preston Executive Drive Cary, NC Ph(919) Fax(919) Page 1 of 6. Patient History
130 Preston Executive Drive Cary, NC 27513 Ph(919)462-8081 Fax(919)462-8082 www.parkwaysleep.com Page 1 of 6 Patient History *Please fill out in dark BLACK INK only. General Information Name Sex: Male
Medications. New Patient Registration. Billing and Insurance. Phone Calls. Prescription Refills. Lab Results and Test Results
Dear New Patient: We would like to welcome you to our practice. Our goal is to make your experience with us as pleasant as possible. In order to help us meet this goal we have listed some helpful hints