Adult Behavioral Health Information

1. Name

2. Briefly describe the specific problem(s) you wish to change. How long has this issue(s) been a problem.

Anxiety

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

Yes No

If you answered "No" to question #4 skip to #7

5. If you have had an anxiety attack (panic attack) in the last 2 weeks,

Has this happened before?

Yes No

Do some of these attacks come suddenly out of the blue-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

6. Think about your last anxiety/panic attack and select the symptoms from the list below:

Shortness of breath

Yes No

Heart racing, pounding or skipping

Yes No

Chest pain or pressure

Yes No

Sweating

Yes No

Sense of choking

Yes No

Hot flashes or chills

Yes No

Nausea, upset stomach, a feeling that you were going to have diarrhea

Yes No

Dizziness, unsteady, faint

Yes No

Tingling or numbness in parts of the body

Yes No

Trembling or shaking

Yes No

Fear of dying

Yes No

7. Over the past 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 #7, SKIP to question #9

8. 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 it is hard to sit still

0 1 2

Getting tired very easily

0 1 2

Muscle tension, aches, soreness

0 1 2

Trouble falling asleep or staying asleep

0 1 2

Trouble concentrating on things, such as reading or watching TV

0 1 2

Becoming easily annoyed or irritable

0 1 2

9. Eating/weight difficulties

9a. Do you often feel you can't control what or how much you eat?

Yes No

9b. Do you often eat, within any 2 hour period, what most people would regard as an unusally large amount of food?

Yes No

Frequency of #9a or #9b in the past 3 months

0-1 times a week 2-3 times a week 4 or more a week

10. 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 does of laxatives?

Yes No

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

Yes No

Exercised for more than an hour (specifically to avoid weight gain due to binge eating)?

Yes No

11. If you answered "yes" to any of these ways to avoid gaining weight, please select the frequency of these efforts over the past 3 months

0-1 times a week 2-3 times a week 4 or more times a week

Mood Instability

12. Have you been bothered by any of the following problems for at least 1 week? Use the scale below to respond:

0 Not at all
1 Several days
2 More than half of the days
3 Nearly every day

Extreme happiness, hopefulness and exhilaration

0 1 2 3

Restlessness, increased energy, and little/no need for sleep

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 [heightened beliefs about your ability, intelligence and powers]

0 1 2 3

Alcohol/Drug use

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

Yes No

Have any of the following happened to you more than once in the past 6 months?

14. Have you drank alcohol even though a doctor suggested that you stop because of problems with your health?

Yes No

15. Have you drank or were hung over due to alcohol while working, going to school or taking care of children or other responsibilties

Yes No

16. Were you late or did you miss work, school or other activities because you were drinking or hung over?

Yes No

17. Have you or do you have problems getting along with others while you were drinking?

Yes No

18. Have you driven a car after having several drinks or after drinking too much?

Yes No

19. For Men, in the past year, how ofen have you had 5 or more drinks in a day?

20. For women, in the past year, how often have you had 4 or more drinks in one day?

21. In the past 3 months, did you use marijuana (hash, weed)?

Yes No

22. In the past 3 months, have you had a strong desire or urge to use marijuana at least once a week or more often?

Yes No

23. In the past 12 months, how often have you used cocaine/crack, herion, methamphetamine, hallucinogen, ecstasy/MDMA?

Never Monthly Less than monthly Weekly Daily or almost daily

24. In the past 12 months, have you used prescription medications more than prescribed or used medications not prescribed for you? This includes: OxContin, Vicodin, Percocet, Methadone, Xanax, Ativan, Klonopin, Adderall, Ritalin.

Never Monthly Less than monthly Weekly Daily or almost daily

25. 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

26. Who is your Primary Care Physician (PCP)

27. PCP Address and Phone Number

28. Date of last physical exam

29. 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

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

32. If you are being treated for any of the above, please describe treatment.

33. List all prescribed and over-the-counter medications you currently take.

34. List any drug, medication or other substance to which you are allergic.

35. Do you exercise regularly?

Yes No

36. Do you eat a well-balanced diet?

Yes No

Previous Behavioral Health Treatment

37. Please list all of the behavioral health and chemical dependency treatment you have had, including dates, therapists, if hospitalized and/or medications.

Family History

38. State the status of your parent's relationship

Married Divorced Never Married

39. Describe your parent's relationship (ie., positive, estranged, conflctual, stable, etc)

40. How many siblings do you have and what are their ages?

41. Descibe your view of your family's dynamics.

42. Please list family members who have been treated for emotional problems (e.g, anxiety, depression, schizophrenia, suicide), drug/alcohol or brain disease (Alzheimer's, stroke)

Other

43. Are you currently involved in court proceedings or litigations such as child custody, worker's compensation, auto accident or criminal proceedings? Please explain.

44. Please add any additional information that you believe may be helpful.

Your information will be encrypted.