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Adult Questionnaire

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Briefly describe your concerns
Please list any current medications and daily dosage -over the counter, vitamins, herbs, and supplements
Please include beneficial side effects, side effects, reason it was discontinued, when and how long you took the medication
Have you ever been hospitalized or in an in-patient facility for a mental health issue?
Have you ever attempted suicide?
Are you currently experiencing suicidal thoughts or have a plan to harm yourself?
Behavioral Health History : Have you had past or current outpatient mental health treatment ?
Provider/Date
Provider/Date
Provider/Date
Provider/Date
Who is living in the home and their relationship to the patient
Do you or a family member have a history or prior diagnosis of : ADD/ADHD
Anxiety
Bipolar Disorder
Depression
Eating Disorder
Encopresis/Enuresis
Hallucinations/Delusions/Paranoia
OCD
Panic Attacks
Personality Disorder
PTSD/Trauma
Substance Abuse/Dependence
Other
Other
Medical History : Primary Care Physician
Additional healthcare providers
Are you currently experiencing any pain
Do you or a family member have a history or prior diagnosis of Asthma
Cancer
Concussion/Head Injury
Diabetes
Dyslipidemia
Endocrine Disorder
Heart Disease
High Blood Pressure
Kidney Disease
Liver Disease
Seizures
Stroke
Thyroid Problems
Other
Tobacco / Alcohol / Prescription Medication / Other Substance Use : In the past 12 months, how often have you used tobacco ?
e-cigarette, vaping, or chewing tobacco
In the past 12 months, how often have you had 5 or more drinks containing alcohol in one day?
In the past 12 months, how often have you used any prescription medications just for the feeling, more than prescribed or that were not prescribed for you?
In the past 12 months, how often have you used any drugs including marijuana, cocaine, or crack, heroin, methamphetamine, hallucinogens, ecstasy/MDMA?
Do you have any concerns about your eating or exercise habits (if yes, please specify)
Highest education completed (less than grade 12, specify grade)
Current Student?
Occupational History
Military Experience
Discharge status
Relationship to patient
Online Therapy

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