Patient Information Questionnaire Step 1 of 9 0% This form is confidential and is designed to help your healthcare professional organize and gather information about you, your history, and the concerns that have led you to seek treatment. Please fill out as much as you are able. If, for any reason, you would rather not answer certain questions, feel free to leave them blank or write in “need to discuss.” Thank you.Personal & Contact InformationName* First Last SSN* DOB* Gender* Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Receive Mail Okay to receive mail here? Home Phone*Okay to phone Okay to phone Okay to leave message Okay to leave message Preferred Email Address* Enter Email Confirm Email (Please note that email is not a secure, never send your personal details to the office via email.)Preferred Method of Contact Cell Phone Home Phone Email Mail Other How did you hear about Unfold Psychology? Cell Medical Referral Website Psychology Today Presentation Friend or Family Mental Health Referral Other Relationship Status* Sexual Orientation* Race / Ethnicity* Language(s) Spoken* Religious Or Spiritual Affiliation* Are You Currently Active In Your Religion?* Presenting ProblemPlease State Briefly What Has Prompted You To Seek Treatment At This Time?*How Long Have You Been Experiencing This Problem(s)?* Please Identify Any Of The Below That Are Of Concern At This Time (Please Check All That Apply)Please Identify Any Of The Below That Are Of Concern At This Time (Please Check All That Apply) Difficulty Sleeping Fatigue / low energy Procrastination Motivation Academic / Work Concerns Assertiveness Trouble Concentrating Stress Management Athletic Performance Perfectionism Self-Esteem Decision Making Learning Problems Phobias Panic Attacks Nightmares Anger Issues Feeling Guilty Please Identify Any Of The Below That Are Of Concern At This Time (Please Check All That Apply) Relationship Concerns Relationship Conflict Infidelity Family Problems Sexual Health Concerns Life Transition Infertility Concerns Physical Abuse / Assault Sexual Abuse / Assault Cultural Concerns Sexual Orientation Gender Identity Personal Growth Clarification of Values Diet and Weight Loss Disordered Eating Shyness Loneliness Spiritual or Religious Concerns Please Identify Any Of The Below That Are Of Concern At This Time (Please Check All That Apply) Paranoia Loss or Grief Alcohol or Drug Concerns Injury Recovery / Rehab Legal Concerns Compulsive Behavior Feelings of detachment / unreality Intrusive Upsetting Thoughts Intrusive Upsetting Memories Cutting or Self Injury Thoughts of Suicide Medical / Health Concerns Mood Swings Trauma Depressed Mood Anxiety Episodes of Manic Behavior Obsessive Thoughts Racing Thoughts Out Of The Items Checked Above, Please List Your Top 3 Concerns In Order Of Importance1.* 2.* 3.* How Would You Rate Your Current Level Of Distress Regarding The Concerns You Listed Above?* 1 (Minimal) 2 3 4 5 (Moderate) 6 7 8 9 10 (Severe) Please Rate To What Degree Your Concern(S) Affect Your Day-To-Day Functioning* 1 (Minimal) 2 3 4 5 (Moderate) 6 7 8 9 10 (Severe) Education & Work HistoryHighest Education Completed* Some High School High School Diploma Some College Associate’s Degree Bachelor’s Degree Some Graduate School Master’s Degree Doctoral Degree What Type Of Grades Did You Typically Get In School?* Have You Been Diagnosed With A Learning Disability?* Yes No Have You Ever Suspected You May Have A Learning Disability?* Yes No Are You Currently Employed?* Yes No Job Title / Description*How Long Have You Been At Your Current Position?* Approximately How Many Jobs Have You Had In Your Adult Life?* Family HistoryWhere Were You Born?* Were You Adopted?* Yes No Do you have any knowledge of your birth family? Where Did You Grow Up?* How Many Times Did You Move Before You Were 18 Years Old?* Did Your Parents Divorce Or Separate?* Yes No Please List The (First) Names And Ages Of Your Immediate Family Members (E.G., Parents, Siblings, Children, Significant Caretakers) and the Quality of the relationship i.e. okay.How Old Were You At The Time? Name Relation Age Quality Name Relation Age Quality Name Relation Age Quality Name Relation Age Quality Name Relation Age Quality Name Relation Age Quality Name Relation Age Quality Name Relation Age Quality Has Anyone In Your Immediate (Parents, Siblings, Children) Or Extended Family (Grandparents, Cousins, Etc.) Been Diagnosed With Any Of The Following? Or Do You Suspect That They May Have Any Of The Following? Disordered Eating Attention problems or ADD/ADHD Addiction issues (alcohol, drugs, gambling) Depression Anxiety, fears, phobias Bipolar Disorder / Manic Depression Schizophrenia Other Please elaborate briefly on the above checked items. Medical HistoryDate Of Last Physical Exam:* MM slash DD slash YYYY Results Of Exam*Have You Ever Been Hospitalized For A Medical Condition? Yes No Please explain your hospitalization.Have You Ever Suffered A Severe Head Injury With Loss Of Consciousness Or Concussion? Yes No Please explain your head injury.Do You Have Chronic Pain? Yes No Please explain your chronic pain.Please List Past And Present Medical Conditions, Problems And/Or DiagnosesPrimary Care Provider (Name, Phone, Address)Psychiatrist / Psychologist / Psychotherapist (Name, Phone, Address)Please List All Medications (And Dosage) You Are Currently Taking (Please Include Prescription Medication, Over-The-Counter Medication, Vitamins, Oral Contraceptives And Alternative Remedies)Please List All Psychotropic Medications You Have Taken In The Past, If Any (Please Include Dosage, Dates Of Use And Any Side Effects)History OfCheck OneDetails and DatesNeurologic disordersYes / No Yes No Details and Dates Seizure disordersYes / No Yes No Details and Dates Respiratory disordersYes / No Yes No Details and Dates Cardiovascular disordersYes / No Yes No Details and Dates Hematopoietic-lymphatic disordersYes / No Yes No Details and Dates Eyes/Ears/Nose/Throat DisordersYes / No Yes No Details and Dates Hepatic DisordersYes / No Yes No Details and Dates Dermatologic DisordersYes / No Yes No Details and Dates Musculoskeletal DisordersYes / No Yes No Details and Dates Endocrine-Metabolic DisordersYes / No Yes No Details and Dates Gastrointestinal DisordersYes / No Yes No Details and Dates Renal-Genitourinary DisordersYes / No Yes No Details and Dates Sexual DisordersYes / No Yes No Details and Dates MalignanciesYes / No Yes No Details and Dates Allergies or Drug SensitivitiesYes / No Yes No Details and Dates Major Surgical ProceduresYes / No Yes No Details and Dates Vision problemsYes / No Yes No Details and Dates Sexually Transmitted Disease(s) / Infection(s)Yes / No Yes No Details and Dates Daytime SleepinessYes / No Yes No Details and Dates Difficulty SleepingYes / No Yes No Details and Dates Unusual DietYes / No Yes No Details and Dates Memory ProblemsYes / No Yes No Details and Dates Recurring HeadachesYes / No Yes No Details and Dates Shortness of BreathYes / No Yes No Details and Dates Serious Head InjuryYes / No Yes No Details and Dates Alcohol AbuseYes / No Yes No Details and Dates Other Substance Abuse HistoryYes / No Yes No Details and Dates Other-GeneralYes / No Yes No Details and Dates Were There Any Complications At Your Birth? (E.G., Premature Birth, Medical Problems)* Yes No Please explain the ComplicationsDid You Experience Any Problems In Your Early Development (E.G., Learning To Walk, Talk, Etc.)?* Yes No Please explain the developmental problemsFor Female PatientsAge Of First Period? How Many Total Pregnancies Have You Carried To Term? Which Best Describes Your Menstrual Cycle Now?* Regular Irregular Pre-menopausal Menopausal Post-Menopausal Relationship HistoryAge At First Significant Romantic Relationship?* Total Number Of Marriages / Long Term (Over 1 Year) Relationships* If You Are Married / Partnered, Please Briefly Describe Your RelationshipIf You Are Currenlty Single, Divorced, Separated Or Widowed, Please Briefly Describe Your Last Long Term Relationship Mental Health HistoryHave You Ever Sought Mental Health Treatment? Yes No Please complete the following about your past (or present) treatment experience(s)Psychiatry Provider Name Provider Contact Info Approximate Dates Problem(s) Addressed? Was Treatment Helpful? Psychiatry Provider Name Provider Contact Info Approximate Dates Problem(s) Addressed? Was Treatment Helpful? Psychiatry Provider Name Provider Contact Info Approximate Dates Problem(s) Addressed? Was Treatment Helpful? Have You Ever Been Hospitalized For A Psychiatric Condition? Yes No Please describe the circumstances of your hospitalization (how long, name of facility, dates)Have You Ever Been Admitted To Residential Or Intensive Outpatient Treatment? Yes No Please describe the circumstances of your treatment (how long, name of facility, dates)Do You Use Tobacco? Yes No Please indicate the amount and frequencyHow Many Beverages Containing Alcohol Do You Consume In A Typical Week?* How Many Beverages Containing Caffeine Do You Consume In A Typical Day?* Have You Used Any Drugs In The Past 30 Days That Were Not Prescribed By A Healthcare Professional (E.G., Marijuana, Hash, Cocaine, Adderall, Diet Pills, Ecstasy, Valium, Lsd, Acid, Mushrooms, Heroin, Vicodin, Codeine, Or Other)?* Yes No Please describe (including the amount and frequency)Has Anyone Ever Suggested You Drink Alcohol Or Use Drugs To Excess?* Yes No Have You Ever Been In Treatment For Substance And/Or Alcohol Use?* Yes No Please describe the circumstances of your treatment (how long, name of facility, dates)Approximately How Many Hours Per Day Do You Spend Online?Social Networking SitesHours* YoutubeHours* GamingHours* BrowsingHours* ShoppingHours* ShoppingHours* GamblingHours* Pornography SitesHours* OtherHours* Do You Feel Your Technology Use Is Balanced? Yes No Do You Ever Have Problems Controlling The Amount Of Food You Eat? Yes No Please DescribeHow Many Times Per Year Do You Gamble (Online Or Other)?* Have You Ever Had Thoughts Of Harming Yourself?* Yes No Please Describe The Types Of Thoughts (Including Frequency, Intensity And Duration)Have You Ever Purposely Injured Yourself Without Suicidal Intent (E.G., Cutting, Hitting, Burning)?* Yes No Please Describe The Types Of Behavior(S) (Including Frequency, Intensity And Duration)In The Past Few Weeks, Have You Had Thoughts Of Suicide?* Yes No Please Describe The Types Of Thoughts (Including Frequency, Intensity And Duration) And Whether You Have Acted on these thoughtsHave You Seriously Considered Suicide In The Past?* Yes No Please DescribeHave You Ever Attempted Suicide?* Yes No Please DescribeHave You Ever Seriously Considered Harming Another Person?* Yes No Please DescribeHave You Ever Intentionally Physically Harmed Another Person?* Yes No Please DescribeDo You Currently Have Thoughts Of Harming Another Person?* Yes No Please DescribeHas Anyone In Your Family Attempted Or Committed Suicide?* Yes No Please DescribeDo You Currently Have Access To Any Weapons, Including Firearms?* Yes No Please Describe Legal HistoryHave You Ever Been Arrested Or Convicted Of A Crime?* Yes No Please Describe (Including When)Are You Presently Involved In A Lawsuit?* Yes No Please DescribeAre You Seeking Treatment Due To An Accident Or Injury?* Yes No Please DescribeAre You Required By A Court, The Police Or A Probation/Parole Officer To Be In Treatment?* Yes No Please Describe ReflectionsWhat Gives You The Most Pleasure In Your Life?*What Are Your Main Worries Or Fears?*What Are Your Most Important Hopes And Dreams?*OtherIs There Anything Else You Would Like Your Healthcare Professional To Know?CommentsThis field is for validation purposes and should be left unchanged.