Problem Summary This questionnaire is an important part of providing you with the best health care possible. Your answers will help in understanding problems that you may have. Please answer every question to the best of your ability unless you are requested to skip over a question. * 1. Name * 2. Briefly describe the specific problem(s) you wish to change. Please estimate the length of time the problem has been present 3. In the last 4 weeks, have you been bothered by the following Stomach pain t Bothered Bothered a Little Bothered a Lot Back pain Pain in your arms, legs, or joints (knees, hips, etc.) Menstrual cramps or other problems with your periods Pain or problems during sexual intercourse Headaches Chest pain Dizziness Fainting spells Feeling your heart pound or race Shortness of breath Constipation, loose bowels, or diarrhea Nausea, gas, or indigestion
4. Over the last 2 weeks, how often have you been bothered by any of the following problems? t at all Several days More than half the days Nearly every day Little interest or pleasure in doing things Feeling down, depressed, or hopeless Trouble falling or staying asleep, or sleeping too much Feeling tired or having little energy Poor appetite or overeating Feeling bad about yourself or that you are a failure or have let yourself or your family down Trouble concentrating on things, such as reading the newspaper or watching television Moving or speaking so slowly that other people could have noticed? Or the opposite being so fidgety or restless that you have been moving around a lot more than usual Thoughts that you would be better off dead or of hurting yourself in some way
5. Have you been bothered by any of the following problems for at least one week? t at all Several days More than half the days Nearly every day Extreme happiness, hopefulness, and exhilaration Restlessness, increased energy, and need for little or no sleep Talking rapidly or excessively Racing thoughts Higher than your normal sex drive Making grand and unachievable plans Showing poor or impulsive judgment Inflated self-esteem or grandiosity -- greatly heightened beliefs about your ability, intelligence, and powers Increased reckless or self injuring behaviors (such as spending sprees, driving recklessly, impulsive sexual indiscretions, abuse of alcohol or drugs, or ill-advised business decisions) 6. In the last 4 weeks, have you had an anxiety attack suddenly feeling fear or panic? If you answer "" to question #6, skip to Question #9.
7. If you have had an anxiety attack or panic attack in the last 2 weeks, Has this ever happened before? Do some of these attacks come suddenly out of the blue that is, in situations where you don t expect to be nervous or uncomfortable? Do these attacks bother you a lot or are you worried about having another attack? 8. If you have had panic attacks, think about your last panic attack Were you short of breath? Did your heart race, pound, or skip? Did you have chest pain or pressure? Did you sweat? Did you feel as if you were choking? Did you have hot flashes or chills? Did you have nausea or an upset stomach, or the feeling that you were going to have diarrhea? Did you feel dizzy, unsteady, or faint? Did you have tingling or numbness in parts of your body?... Did you tremble or shake? Were you afraid you were dying?
9. Over the last 4 weeks, how often have you been bothered by any of the following? t at all Several days More than half the days Feeling nervous, anxious, on edge, or worrying a lot about different things. If you answered "t at all" to question #9, SKIP to question #11 10. Over the last 4 weeks, how often have you been bothered by any of the following problems? t at all Several days More than half the days Feeling restless so that it is hard to sit still. Getting tired very easily. Muscle tension, aches, or soreness. Trouble falling asleep or staying asleep. Trouble concentrating on things, such as reading a book or watching TV. Becoming easily annoyed or irritable. 11. Questions about eating. Do you often feel that you can t control what or how much you eat? Do you often eat, within any 2-hour period, what most people would regard as an unusually large amount of food? 12. If you responded "" to either of the questions in question #11, has this been as often, on average, as twice a week for the last 3 months?
13. In the last 3 months have you often done any of the following in order to avoid gaining weight? Made yourself vomit? Took more than twice the recommended dose of laxatives? Fasted not eaten anything at all for at least 24 hours? Exercised for more than an hour specifically to avoid gaining weight after binge eating? 14. If you checked YES to any of these ways of avoiding gaining weight, were any as often, on average, as twice a week? 15. Do you ever drink alcohol (including beer or wine)?
16. Have any of the following happened to you more than once in the last 6 months? You drank alcohol even though a doctor suggested that you stop drinking because of a problem with your health. You drank alcohol, were high from alcohol, or hung over while you were working, going to school, or taking care of children or other responsibilities. You missed or were late for work, school, or other activities because you were drinking or hung over. You had a problem getting along with other people while you were drinking. You drove a car after having several drinks or after drinking too much 17. For Men, in the past year, how often have you had 5 or more drinks in a day? 18. For Women, in the past year, how often have you had 4 or more drinks in one day? 19. In the past year, how often have you used prescription drugs for non-medical reasons 20. In the past year, how often have you used illegal drugs?
21. If you checked off any problems on this questionnaire, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? t difficult at all Somewhat difficult Very difficult Extremely difficult Medical and Physical History 22. Who is your Primary Care Physician (PCP)? 23. PCP Address and Phone Number 24. Date of last physical exam * 25. It may be beneficial for your therapist to communicate with your PCP. Please check here if you give your consent for us to communicate with your PCP. 26. Please list all of your medical hospitalizations, including the dates, reasons for the hospitalizations, hospitals and physicians
27. Please check all of the medical problems that you are experiencing Cancer Epilepsy (seizures) Arthritis Chronic Pain Digestive Problems Multiple Sclerosis Gynecological Hypertension Diabetes Heart Problems Breathing Problems Head Injury Genital/Urinary Problems Headaches Stroke Other 28. If you are being treated for any of the above, please describe the treatment 29. List all prescribed and over the counter medications you take regularly 30. List any drug, medication or other substance to which you are allergic
31. Do you exercise regularly? 32. Do you eat a well-balanced diet? Previous Behavioral Health Treatment 33. Please list all of the behavioral health and chemical dependency treatment you have had, including dates, therapists or hospital, problem(s) and/or medication(s) Family History 34. Were your parents married, divorced or never married? Married, please state your view of the marriage below Divorced, please state your age at the time of the divorce and view of the divorce below Other, please elaborate a little below Describe 35. How many siblings to you have and what are their ages? 36. Describe the family dynamics in your family of origin
37. Please list family members who have been treated for emotional problems (e.g. anxiety, depression, schizophrenia, suicide), drug/alcohol issues or brain disease (e.g. Alzheimer s, stroke) Other 38. Are you currently involved in court proceedings or litigations such as child custody, worker s compensation, auto accident or criminal proceedings? Please explain 39. Please add any additional information that you believe may be helpful