Adult Behavioral Health Information

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 often have you been bothered by the following:

For the following questions, please indicate a

0 Not Bothered At All
1 Bothered a Little
2 Bothered a Lot

Stomach Pain

0 1 2

Back Pain

0 1 2

Headaches

0 1 2

Chest pains

0 1 2

Dizziness

0 1 2

Pain in arms, legs or joints

0 1 2

Shortness of breath

0 1 2

Heart Pounding or racing

0 1 2

Fainting Spells

0 1 2

Constipation, loose bowels or diarrhea

0 1 2

Nausea, gas or indigestion

0 1 2

Pain or problems during intercourse

0 1 2

For women: Menstrual cramps or problems with period

0 1 2

4. Over the last 2 weeks, how often have you been bothered by any of the following problems? For the following questions, please indicate if you have experienced these problems--

0 Not at All
1 Several Days
2 More than Half the Days
3 Nearly Every Day

Little interest or pleasure in doing things.

0 1 2 3

Feeling down, depressed, or hopeless.

0 1 2 3

Trouble falling or staying asleep, or sleeping too much.

0 1 2 3

Feeling tired or having little energy.

0 1 2 3

Poor appetite or overeating

0 1 2 3

Feeling bad about yourself or that you're a failure or have let yourself or your family down.

0 1 2 3

Trouble concentrating on things, such as reading the newspaper or watching television.

0 1 2 3

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.

0 1 2 3

Thoughts that you would be better off dead or of hurting yourself in some way.

0 1 2 3

5. Have you been bothered by any of the following problems for at least one week? For the following issues, please use the following scale.

0 Not at all
1 Several Days
2 More than Half the Days
3 Nearly Every Day

Extreme happiness, hopefulness and exhilaration

0 1 2 3

Restlessness, increased energy, and need for little or no slepp

0 1 2 3

Talking rapidly or excessively

0 1 2 3

Racing Thoughts

0 1 2 3

Higher than your normal sex drive

0 1 2 3

Making grand and unachievable plans

0 1 2 3

Showing poor or impulsive judgment

0 1 2 3

Inflated self-esteem or grandiosity--greatly heightened beleifs about your ability, intelligence and powers

0 1 2 3

Increased reckless or self injuring behaviors (such as spending sprees, driving recklessly, impulsive sexual indiscretions, abuse of alcohol or drugs, or ill-advised business decision.

0 1 2 3

Anxiety

6. In the last 4 weeks, have you had an anxiety attack - suddenly feeling fear or panic

Yes No

If you answered "No" 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?

Yes No

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

Yes No

Do these attacks bother you a lot or are you worried about having another attack?

Yes No

8. If you have had panic attacks, think about your last panic attack

Were you short of breath?

Yes No

Did your heart race, pound, or skip?

Yes No

Did you have chest pain or pressure?

Yes No

Did you sweat?

Yes No

Did you feel as if you were choking?

Yes No

Did you have hot flashes or chills?

Yes No

Did you have nausea or an upset stomach, or the feeling that you were going to have diarrhea

Yes No

Did you feel dizzy, unsteady, or faint?

Yes No

Did you have tingling or numbness in parts of your body?

Yes No

Did you tremble or shake?

Yes No

Were you afraid you were dying?

Yes No

9. Over the last 4 weeks, how often have you been bothered by feeling nervous, anxious, on edge, or worrying a lot about different things.

Not at all Several Days More than half the days

If you answered "Not 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. Use the scale below

0 Not at all
1 Several Days
2 More than Half the Days

Feeling restless so that it is hard to sit still.

0 1 2

Getting tired very easily.

0 1 2

Muscle tension, aches, or soreness.

0 1 2

Trouble falling asleep or staying asleep.

0 1 2

Trouble concentrating on things, such as reading a book or watching TV.

0 1 2

Becoming easily annoyed or irritable.

0 1 2

11. How's your Eating?

Do you often feel that you can’t control what or how much you eat?

Yes No

Do you often eat, within any 2-hour period, what most people would regard as an unusually large amount of food?

Yes No

12. If you responded "Yes" to either of the questions in question #11, has this been as often, on average, as twice a week for the last 3 months?

Yes No

13. In the last 3 months have you often done any of the following in order to avoid gaining weight?

Made yourself vomit?

Yes No

Took more than twice the recommended dose of laxatives?

Yes No

Fasted - not eaten anything at all for at least 24 hours?

Yes No

Exercised for more than an hour specifically to avoid gaining weight after binge eating?

Yes No

14. If you checked “YES” to any of these ways of avoiding gaining weight, were any as often, on average, as twice a week?

Yes No

Alcohol Use

15. Do you ever drink alcohol (including beer or wine)?

Yes No

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.

Yes No

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.

Yes No

You missed or were late for work, school, or other activities because you were drinking or hung over

Yes No

You had a problem getting along with other people while you were drinking.

Yes No

You drove a car after having several drinks or after drinking too much

Yes No

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?

Not Difficult Somewhat Difficult Very Difficult Extremely Difficult

MEDICAL & 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.

Yes No

26. Please list all of your medical hospitalizations, including the dates, reasons for the hospitalizations, hospitals and physicians.

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?

Yes No

32. Do you eat a well-balanced diet?

Yes No

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 do 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.

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