Date: To be completed by Patient Client Questionnaire Client(s) Name: SSN#: - - Name of Person Completing Form: Relationship to Patient: (if other than client) Marital Status of Client Race/Ethnic Origin of Client (Optional) Sex of Client Custody Never Married Divorced White American Indian Male (if client is dependent) Married Separated African American Asian Female Mother: Cohabitating Widowed Hispanic Bi-Racial Father: Other Joint: Other: Present Living Arrangement: Alone Family Friends Foster Care Guardian Other (please describe: Client: Immediate Family Age Sex Relationship Living in Household Yes No Occupation Notify in Case of Emergency (Please notify therapist of any change during treatment) Name: Home #: Cell #: Employment Status: Full-time (35 or more hrs/week) Retired Part-time (less than 35 hr/week) Homemaker Employed, not working due to extended illness Full-time student Unemployed Seasonal worker Other (please describe): Occupation: Page 1
Client Name: Alexian Brothers Behavioral Health Hospital 1786 Moon Lake Boulevard Education: Case #: High School/G.E.D. Yes No Special Training: Hoffman Estates, IL 60194 847-755-8090 Last Grade completed: Highest Degree: Client Questionnaire Form # 6010-286 (3/08) Page 1 of 5 Currently attending school/grade: Briefly explain why you are seeking help at this time: SYMPTOMS Are you currently suicidal? Suicidal thoughts only? Previous suicide attempt at any time? Yes No Yes No Are you currently engaged in aggressive/violent behavior? Do you have aggressive/violent thoughts? Have you had aggressive/violent behavior or thoughts? Please check off any of the following that apply: Depressed mood Daily irritability Recurrent and persistent, thoughts/behaviors Lack of interest or pleasure Increase in appetite Increased need to sleep Physical abuse Recurrent distressing dreams Restlessness or inability to concentrate Fatigue or loss of energy Feelings or worthlessness or guilt Feeling of hopelessness Recurrent thoughts of death Racing thoughts or ideas Rapid mood swings Current Past Current Past Fear of dying or going crazy Excessive fear of persons, places, animals, objects, situations Difficulty controlling anger/bad temper in activities Loss of appetite Decreased need for sleep Psychological abuse Sexual abuse Distressing memories that recur or intrude Difficulty making decisions Delusions (unreasonable thoughts or beliefs) Do you hear or see things that others don t? Not able to control impulse to steal? Preoccupation with/or frequent gambling? Distractibility Sense of reliving traumatic events Intense reactions to certain events or anniversaries Shortness of breath/dizziness Periods of time which you cannot remember Avoidance of thoughts or feelings of trauma Accelerated heart rate or chest pains Trembling or shaking Choking Nausea or abdominal stress Feeling unreal Numbness or tingling sensations Compulsive exercising Self injury Detachment from feelings, people and places Sweating/feeling flushed Bingeing/compulsive overeating Intentional vomiting Diuretics or laxative misuse Excessive dieting Physical pain Other Page 2
HEALTH QUESTIONNAIRE A. What medical problems or concerns, if any, are you currently having? Are those problems being treated? Yes No By Whom? B. Are you experiencing any physical pain, either constantly or occasionally? Yes No How much does the pain interrupt your daily living/working? 1 2 3 4 Not At All Severely Are these problems being treated? Yes No By Whom? C. Last medical examination (date): Primary care doctor: Phone Number: What prescription or non-prescription drugs are you currently taking or have taken in the last six months? 1. 4. 2. 5. 3. 6. ALLERGIES: Drug, food, other (list) Type of reaction: List past hospitalizations (including psychiatric), operations, or serious illnesses: Type of Illnesses/Operations Year Hospital or Doctor 1. 2. 3. Are you currently pregnant? Yes No N/A Is your menstrual period regular? Yes No N/A What was the date of your last menstrual period? Page 3
Check any of the following that apply: Tuberculosis Liver Disease Heart Disease Chronic Bronchitis Ulcer (Stomach) or Duodenus Stroke Emphysema Sexually Transmitted Disease Jaundice Rheumatic Fever Kidney Disorder Hepatitis Thyroid Disorder High Blood Pressure Asthma Diabetes Pancreatitis Anemia Cancer Epilepsy (Convulsions) Other: Family History of serious illnesses, familial disease, including mental disorders and substance abuse: NUTRITION SCREEN Please give as much detail as you can for either yourself or other as you complete this nutrition screen. 1. Has there been any recent change in your appetite? Yes No Excellent Good Fair Poor 2. What is your Height Current Weight Usual Weight 3. Have you gained or lost weight in the past year? Yes No If so, how much? Gained pounds OR Lost pounds 4. Do you omit any foods because of health reasons? Yes No If yes, what are they? 5. Do you omit any foods because of religious reasons? Yes No If yes, what are they? 6. Do you include any foods because of health benefits? Yes No If yes, what are they? 7. Do you have any difficulty with: Swallowing Chewing Diarrhea Constipation Vomiting Indigestion Heartburn 8. Do you use any purging methods? Laxatives Diuretics Diet Pills Vomiting 9. What type of exercise do you do? Page 4
10. Do you take vitamins or supplements? Yes No 11. Do you have any food allergies? Yes No 12. How often do you eat meals with family/significant others? 13. How often do you eat out? Which meals do you eat out most often? CHEMICAL USE HISTORY Current Past 1. Do you believe you have a substance abuse problem? Yes No Yes No Current Past 2. Does someone else in your life believe you have an alcohol or substance abuse problem? Yes No Yes No If you answered yes to any of the above, please describe: Alcohol frequency/amount? Drug use frequency/amount? Daily tobacco usage: Caffeine daily usage: Client s Signature: Date: Provider s Signature: Date: Page 5