Name:
Date:
Address:
Phone:
Email:
DOB:
Sex:
Primary Physician:
Current Therapist:
What is your major complaint:
Start Date:
Have you previously suffered from this complaint?
Previous therapist(s) seen for complaint:
Previous treatment for complaint:
Aggravating factors:
Relieving factors:
Anxiety
Appetite Issues
Avoidance
Crying Spells
Depression
Excessive Energy
Fatigue
Guilt
Hallucinations
Impulsivity
Irritability
Libido Changes
Loss of Interest
Panic Attack
Racing thoughts
Risky Activity
Sleep Changes
Suspiciousness
Exercise Frequency:
Exercise type:
Allergies:
What medications are you currently using?
Previous diagnosis/mental health treatment:
Previously treated by:
Previous medications:
Dates treated:
Previous medical conditions:
Previous surgeries:
Were you adopted?
If yes, at what age?
How is your relationship with your mother?
How is your relationship with your father?
Siblings and the ages:
Did your parents divorce?
If yes, how old were you?
Did your parents remarry?
Who raised you?
Family member medical conditions:
Treated with medication?
Medications?
Where did you grow up?
How often did you move and where?
How old were you when you left home?
Have any immediate family members died?
Who?
Have any committed suicide?
Describe any neglect you suffered and by whom:
Trauma suffered and by whom:
Abuse suffered and by whom:
Highest education level completed:
Date completed and location:
Have you ever served in the military?
If yes, where?
Dates of service
Highest rank achieved:
Full-time
Part-time
Student
Unemployed
Disabled
Retired
Are you married?
If yes, date of marriage:
Are you divorced?
If yes, date of divorce:
Prior marriages?
If yes, how many?
What is your sexual orientation?
Are you sexually active?
How is your relationship with your partner?
Do you have children?
Dates of Birth:
How is your relationship with your child(ren)?
List anyone else who lives with you:
Are you a member of a religion/spiritual group?
What is your level of involvement?
Have you ever been arrested?
When and why?
Alcohol
Tobacco
Marijuana
Hallucinogens (LSD)
Heroin
Methamphetamines
Cocaine
Stimulants (Pills)
Ecstasy
Methadone
Tranquilizers
Pain Killers
If yes to any, list frequency/dates of use:
Have you ever been treated for drug/alcohol abuse?
If yes, when?
For which substances?
Do you smoke cigarettes?
If yes, how many per day?
Do you drink caffeinated beverages?
Have you ever abused prescription drugs?
If yes, which ones?
