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Afghanistan
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Morocco
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Namibia
Nauru
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Who Referred You?
Home/Work Phone Number
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Reason for this referral?
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HISTORY OF CURRENT CONDITION
Briefly describe the kinds of problems you’ve had that brought about the need for this visit:
When did your problems first begin?
Have the problems improved over time?
Have you had times when you were free from symptoms?
Do you have a history of suicide attempts?
Yes
No
If so, what method(s) did you use?
Were you molested as a child?
Yes
No
Were you ever raped?
Yes
No
HOW have you been able to manage (handle things)?
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MEDICAL HISTORY
Have you been PSYCHIATRICALLY HOSPITALZED?
Yes
No
If “Yes,” please answer the following:
Hospital Year Length of Stay Diagnosis
Have you had SURGERIES?
Yes
No
If “Yes,” please answer the following:
Surgery Year Residual Effects?
Have you had head injuries?
Yes
No
Did you lose consciousness?
Yes
No
Please list other disorders/diseases not named above (e.g., diabetes, thyroid dysfunction, high blood pressure, etc.)
Please list ALL MEDICATIONS you are currently taking. Separate each medication with a dash (-).
Have you had allergic reactions to medications?
Yes
No
If YES, please list medications you cannot tolerate. Separate each medication with a dash (-).
Are you currently under the care of a physician or psychiatrist?
Yes
No
Doctor's Name
Doctor's Fax Number
-
Area Code
Phone Number
Doctor's Office Phone
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Area Code
Phone Number
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FAMILY AND SOCIAL HISTORY
How many brothers/sisters (not including yourself)
Brothers
Sisters
In what state were you born?
Please Select
--Select--
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
In what state were you raised?
Please Select
--Select--
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Who raised you?
If parents divorced, how old were you?
Are both parents living?
Yes
No
If No, who is deceased?
Please Select
--Select--
Mother
Father
Both
How old were you when it happened?
Do you have unresolved differences with OTHER family members??
Yes
No
If "Yes," please list
Did you graduate from high school?
Yes
No
If "No," list last grade completed.
Did you attend college or trade school?
Yes
No
Graduate?
Yes
No
If "Yes," list highest degree or trade
Have you ever been arrested?
Yes
No
If "Yes," please list each charge. Separate each charge with a dash (-).
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How many jobs have you held?
Were you ever fired?
Yes
No
If "Yes," list reasons. Separate each reason with a dash (-).
How many marriages have you had?
How many children have you had?
List childrens' names and ages.
Dates of marriages, spouse's first name, and reasons for divorce.
Have OTHER FAMILY MEMBERS been psychiatrically hospitalized?
Yes
No
If "Yes," which family member(s) were psychiatrically hospitalized?
--Select--
Mother
Father
Brother
Sister
Grandmother
Grandfather
Uncle
Aunt
Cousin
What was their diagnosis?
Has a family member committed suicide?
Yes
No
If "Yes," which family member(s)?
--Select--
Mother
Father
Brother
Sister
Grandmother
Grandfather
Uncle
Aunt
Cousin
Method used?
Describe a normal day in your present condition.
Do you sometimes ignore your personal hygiene?
Yes
No
Do you get out of the house often?
Yes
No
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SUBSTANCE USE HISTORY
Have you abused legal or illegal drugs?
Yes
No
If so, what drugs?
Last time used?
Do you still use drugs?
Yes
No
At what age did you begin using drugs?
Did you ever drink alcohol?
Yes
No
If so, are you still drinking?
Yes
No
At what age did you begin drinking alcohol?
Last time you drank alcohol?
Attend AA or NA?
Yes
No
At its height, how frequently did you use drugs or drink alcohol?
Please Select
--Select--
Daily
Weekends
Couple of times per month
Only for special occasions
Longest period of non-use?
Please Select
--Select--
one day
a few days
one week
two weeks
one month
two months
six months or more
one year
two years
more than two years
What were the consequences of your use?
Are you drug free now?
Yes
No
Are you alcohol free now?
Yes
No
I feel sad a good deal of time.
I have difficulty going to sleep.
I awaken during the night and have difficulty returning to sleep.
I awaken earlier in the morning than I need to and can’t go back to sleep.
I have lost interest in things that I used to enjoy doing.
I have been troubled with a sense of guilt that I can’t control.
I feel worthless.
My energy is low and I feel tired a lot.
I have difficulty maintaining focus on things....my mind wanders.
I hardly ever want to eat.
I am frequently hungry and want to eat a lot.
I find that I am easily upset and am irritable with family members.
I have crying spells, but don’t know why.
I am anxious and worry a lot.
I’ve noticed that I move slowly and am slow to respond to others.
I have had thoughts of harming myself.
I have a plan to harm myself.
I believe I could harm myself.
I intend to harm myself.
I have had thoughts of harming someone else.
I believe I could harm someone else
I intend to harm someone else
There has been a period of time when I was not my usual self and...
I felt so good or so hyper that other people thought I was not my normal self or you were so hyper that you got into trouble?
I was so irritable that I shouted at people or started fights or arguments.
I felt much more self-confident than usual.
I got much less sleep than usual and found I didn’t really miss it.
I was much more talkative or spoke much faster than usual.
Thoughts raced through my head or I couldn’t slow your mind down.
I was so easily distracted by things around me that I had trouble concentrating or staying on track.
I had much more energy than usual.
I was much more active or did many more things than usual.
you were much more social or outgoing than usual, for example, you
telephoned friends in the middle of the night?
you were much more interested in sex than usual?
you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?
spending money got you or your family into trouble?
If you checked more than one of the last 14 boxes, have several of these ever happened during the same period of time? Yes No
How much of a problem did any of these cause you - like being unable to work; having family, money or legal troubles' getting into arguments or fights?
No Problem Minor Problem Moderate Problem Serious Problem
At home, work, or school, I find my mind wandering from tasks that are uninteresting or difficult
I find it difficult to read written material unless it is very interesting or very easy
Especially in groups, I find it hard to stay focused on what is being said in conversations
I have a quick temper... a short fuse
I am irritable, and get upset by minor annoyances
I say things without thinking, and later regret having said them
I make quick decisions without thinking enough about their possible bad results
My relationships with people are made difficult by my tendency to talk first and think later
My moods have highs and lows
I have trouble planning in what order to do a series of tasks or activities
I easily become upset
I seem to be thin skinned and many things upset me
I almost always am on the go
I am more comfortable when moving than when sitting still
In conversations, I start to answer questions before the questions have been fully asked
I usually work on more than one project at a time, and fail to finish many of them
There is a lot of “static” or “chatter” in my head
Even when sitting quietly, I am usually moving my hands or feet
In group activities it is hard for me to wait my turn
My mind gets so cluttered that it is hard for it to function
My thoughts bounce around as if my mind is a pinball machine
My brain feels as if it is a television set with all the channels going at once
I am unable to stop daydreaming
I am distressed by the disorganized way my brain works
I have had episodes where my heart beat very quickly.
During that time, I felt a choking sensation or felt like my throat was constricted.
I broke out in a sweat.
I was shaking.
I felt nauseous, like I might throw up.
I felt short of breath.
I had chest pain.
My vision seemed to be different.
I felt like I needed to run away.
I felt like I was about to die or severely embarrass myself.
I avoid places where this has happened
I worry a lot.
It’s as if my mind plays a game of “what if.....”
I feel keyed up or on edge a lot.
I become tired easily.
Sometimes my mind goes blank.
I am troubled with muscle tension.
I have restless unsatisfying sleep.
I fear many things.
There are certain subjects I avoid talking about
There are some things I cannot watch on TV or in movies
Sometimes I become upset when I see, hear, or smell something familiar, associated with a past event
I startle easily (overreact to certain things such as noises, someone appearing unexpectedly, etc.)
When this happens I become frightened, run away, or strike out
I perform certain rituals or habits over and over.
I wash my hands a lot. (approximate number of times per day )
I take frequent showers or baths. (approximate number of times per day )
I check and recheck things. (what do you check? number of times? )
I find myself counting things or adding numbers for no reason.
I need a lot of order and structure in my life.
I am sometimes troubled with unwanted thoughts that disturb me.
I can’t make the unwanted thoughts go away.
I tend to alternate between seeing people as either flawless or evil.
I have difficulty remembering the good things about a person I’ve cast in the role of villain.
I find it impossible to recall anything negative about this person when they become a hero in my eyes.
I alternate between seeing others as completely for me or against me.
I alternate between seeing situations as either disastrous or ideal.
I alternate between seeing yourself as either worth¬less or flawless.
I have a hard time recalling someone's love for me when they're not around.
I tend to believe that others are either completely right or absolutely wrong.
I change my opinions depending upon who I’m with.
I have often changed from idealizing people to devaluing them.
I seem to remember situations very differently from others, or find myself unable to recall them at all.
I believe that others cause my actions—or I take too much responsibility for their actions.
I’m unwilling to admit to a mistake—or at times feel that everything I do is a mistake.
I base my beliefs on feelings rather than facts.
I’m not sure I realize the effects of my behavior on others.
I feel abandoned at the slightest provocation.
I have extreme mood swings that cycle very quickly (in minutes or hours).
I have difficulty managing my emotions.
I feel emotions so intensely that it's difficult to put oth¬ers' needs (even my own children) ahead of my own.
I am distrustful and suspicious a great deal of the time.
I feel anxious or irritable a great deal of the time.
I feel empty or like I have no self a great deal of the time.
I feel ignored when I’m not the focus of attention.
At times I express anger inappropriately or have difficulty ex¬pressing anger at all.
I feel that I never get enough love, affection, or attention.
Frequently I feel spacey, unreal, or out of it.
I have trouble observing others' personal limits.
I also have trouble defining my own personal limits.
I seem to act impulsively in ways that are potentially self-damaging, such as spending too much, engaging in dangerous sex, fighting, gambling, abusing drugs or al¬cohol, reckless driving, shoplifting, or disordered eating?
I sometimes mutilate myself—for example, purposely cut or burn my skin.
I have threatened to kill myself—or made actual suicide at¬tempts.
I have rushed into relationships based on idealized fantasies of what I would like the other person or relation¬ship to be
Change my expectations in such a way that the other person feels they can never do anything right.
I have frightening, unpredictable rages that make no logical sense—or have trouble expressing anger at all.
I have physically abused others, such as slapping, kicking, and scratching them.
I have needlessly created crises or live a chaotic lifestyle.
I act inconsistently or unpredictably.
I swing from wanting to be close to others, to distancing myself from them. (Examples include picking fights when things are going well or ending relation¬ships and then trying to get back together.)
I have cut people out of my life over issues that seem trivial or overblown.
I act competent and controlled in some situations but extremely out of control in others.
I have verbally abused others, criticizing and blaming them to the point where it feels brutal.
I act verbally abusive toward people I know very well, while putting on a charming front for others.
I can switch from one mode to the other in seconds.
I have acted in what seems like extreme or controlling ways to get my own needs met.
I have done or said something inappropriate to focus the attention on myself when I feel ignored.
I sometimes accuse others of doing things they did not do, having feelings they do not have, or as believing things
they do not believe.
I sometimes hear voices.
I have seen things that others couldn’t see and that would be hard to describe
I feel like someone is following me or is out to get me.
I have inflicted injury upon myself (cutting, biting, or scraping my skin) to relieve the emotional pain I feel.
I have had a problem with fire-setting, bed wetting, or animal cruelty
Other symptoms not mentioned above:
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