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CENTER ASSOCIATES PSYCHIATRIC HISTORY QUESTIONNAIRE
Name
*
Date of Birth:
*
+
Account #
Date
What brings you here today?
*
List other psychiatric providers from whom you have received outpatient care:
Please list psychiatric hospitalizations, including place, approximate date, and reason:
What medications are you taking including over-the-counter, herbal or nutritional supplements? (Skip if you brought a list or medications with you)
Medication
Strength
How Often
1
Medication
Strength
How Often
2
Medication
Strength
How Often
3
Medication
Strength
How Often
4
Medication
Strength
How Often
5
Medication
Strength
How Often
What medications have you taken in the past to help with mood, thinking, behavior, or sleep
Allergies (i.e. drug, bee stings, food):
Surgeries (type, date):
Primary care provider and Specialists (name, clinic, city):
For females: Age of first menses (monthly period):
Last menses
Birth Control Method
.
Last menses
Birth Control Method
Do you have, or have you had any of the following?
Yes
No
Diabetes
Yes
No
Hypoglycemia
Yes
No
Thyroid disorder
Yes
No
Heart Disease
Yes
No
High Blood Pressure
Yes
No
High Cholesterol
Yes
No
Heart Attack
Yes
No
Heart Palpitations
Yes
No
Chest Pain
Yes
No
Stroke/CVA
Yes
No
Dizziness / Fainting
Yes
No
Seizures
Yes
No
Do you have, or have you had any of the following?
Yes
No
Headaches/Migraines
Yes
No
Head Trauma
Yes
No
Liver / Gallbladder Problems
Yes
No
Hepatitis C
Yes
No
Tested Positive for HIV
Yes
No
Kidney Problems
Yes
No
Nausea / Vomiting
Yes
No
Bowel / Bladder Disorders
Yes
No
Bed Wetting
Yes
No
Skin Abnormalities
Yes
No
Glaucoma
Yes
No
Obesity
Yes
No
Do you have, or have you had any of the following?
Yes
No
Sexual Dysfunction
Yes
No
Are you pregnant?
Yes
No
Lung Disease
Yes
No
Asthma / Breathing Difficulties
Yes
No
Cancer
Yes
No
Osteoporosis
Yes
No
Fractures/Broken Bones
Yes
No
Chronic Pain
Yes
No
Fibromyalgia
Yes
No
Rheumatoid/Osteo Arthritis
Yes
No
Sleep Apnea
Yes
No
Insomnia
Yes
No
Other
Do you have, or have you or a family member had any of the following conditions?
Yes
No
Who
Depression
Yes
No
Who
ADHD
Yes
No
Who
Bipolar
Yes
No
Who
Schizophrenia
Yes
No
Who
Anxiety
Yes
No
Who
Post Traumatic Stress
Yes
No
Who
Oppositional Disorder
Yes
No
Who
Borderline Personality
Yes
No
Who
Substance Use:
Age/Year First Used
Age/Year Last Used
How Often Used
How Much Used
Alcohol
Age/Year First Used
Age/Year Last Used
How Often Used
How Much Used
Caffeine
Age/Year First Used
Age/Year Last Used
How Often Used
How Much Used
Cocaine
Age/Year First Used
Age/Year Last Used
How Often Used
How Much Used
Marijuana
Age/Year First Used
Age/Year Last Used
How Often Used
How Much Used
Methamphetamine
Age/Year First Used
Age/Year Last Used
How Often Used
How Much Used
Nicotine
Age/Year First Used
Age/Year Last Used
How Often Used
How Much Used
Prescription drugs abuse
Age/Year First Used
Age/Year Last Used
How Often Used
How Much Used
Other
Age/Year First Used
Age/Year Last Used
How Often Used
How Much Used
Yes
No
Have you ever been in substance abuse treatment?
Yes
No
If so Where & when
*
Do you have, or have you had any of the following?
Yes
No
Have you ever thought you should cut down on your drinking of alcohol?
Yes
No
Has anyone every complained about your drinking?
Yes
No
Have you ever felt guilty or upset about your drinking?
Yes
No
Development/Education
:
Describe any problems your mother had when she was pregnant with you or during your birth:
What, if any, substances did your mother take while pregnant with you, such as alcohol:
Describe any difficulty learning to walk, talk, or meeting any other developmental milestones:
Describe any learning problems or extra help needed in school, including special education classes:
Describe any behavioral problems your have had at school or at work:
How many grades did you or have you completed in school, and where:
Social Background:
Where were you born (city, state)?
Who raised you?
How many brothers/sisters do you have, including half- or step-brothers/sisters?
How do you fit in, age-wise? (Oldest, middle, youngest?)
Military experience:
Have you had any traumatic experiences (may leave blank and discuss with your provider)?
Where do you work and what kind of work do you do?
How long have you been there?
Or: How long unemployed?
Number of times married:
divorced:
widowed:
Number and ages of children
Who all lives with you at present?
Church or social groups you participate in:
Center Associates
9 N. 4th Ave.
Marshalltown, IA 50158