Unfold Psychology

  • About
  • Services
  • Patient Forms
  • Fees
  • FAQs
  • Resources
  • Contact Us
Book An Appointment

Call +1 (650) 993-9321

Patient Forms

  1. Home
  2. Patient Forms

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 Information

  • (Please note that email is not a secure, never send your personal details to the office via email.)
Save and Continue Later
  • Presenting Problem

  • Please Identify Any Of The Below That Are Of Concern At This Time (Please Check All That Apply)

  • Out Of The Items Checked Above, Please List Your Top 3 Concerns In Order Of Importance

Save and Continue Later
  • Education & Work History

Save and Continue Later
  • Family History

  • 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.




Save and Continue Later
  • Medical History

  • MM slash DD slash YYYY
    • History Of
    • Check One
    • Details and Dates
    • Neurologic disorders
    • Seizure disorders
    • Respiratory disorders
    • Cardiovascular disorders
    • Hematopoietic-lymphatic disorders
    • Eyes/Ears/Nose/Throat Disorders
    • Hepatic Disorders
    • Dermatologic Disorders
    • Musculoskeletal Disorders
    • Endocrine-Metabolic Disorders
    • Gastrointestinal Disorders
    • Renal-Genitourinary Disorders
    • Sexual Disorders
    • Malignancies
    • Allergies or Drug Sensitivities
    • Major Surgical Procedures
    • Vision problems
    • Sexually Transmitted Disease(s) / Infection(s)
    • Daytime Sleepiness
    • Difficulty Sleeping
    • Unusual Diet
    • Memory Problems
    • Recurring Headaches
    • Shortness of Breath
    • Serious Head Injury
    • Alcohol Abuse
    • Other Substance Abuse History
    • Other-General
  • For Female Patients
Save and Continue Later
  • Relationship History

Save and Continue Later
  • Mental Health History

  • Please complete the following about your past (or present) treatment experience(s)

  • Approximately How Many Hours Per Day Do You Spend Online?
    • Social Networking Sites

    • Youtube

    • Gaming

    • Browsing

    • Shopping

    • Shopping

    • Gambling

    • Pornography Sites

    • Other




Save and Continue Later
  • Legal History

Save and Continue Later
  • Reflections

  • Other
  • This field is for validation purposes and should be left unchanged.
Save and Continue Later

2608 Laguna St. Suite 101 San Francisco, CA 94123

1955 Mountain Boulevard, Suite 101 Oakland, CA 94611

Contact Information

+1 (650) 993-9321

austin@unfoldpsychology.com

Copyright 2021 Unfold Psychology. All Rights Reserved

  • Terms of Use
  • Privacy Policy