CENTER ASSOCIATES PSYCHIATRIC HISTORY QUESTIONNAIRE

What medications are you taking including over-the-counter, herbal or nutritional supplements? (Skip if you brought a list or medications with you)
 MedicationStrengthHow Often
1
2
3
4
5
For females: Age of first menses (monthly period):
 Last mensesBirth Control Method
.

Do you have, or have you had any of the following?
 YesNo
Diabetes
Hypoglycemia
Thyroid disorder
Heart Disease
High Blood Pressure
High Cholesterol
Heart Attack
Heart Palpitations
Chest Pain
Stroke/CVA
Dizziness / Fainting
Seizures
Do you have, or have you had any of the following?
 YesNo
Headaches/Migraines
Head Trauma
Liver / Gallbladder Problems
Hepatitis C
Tested Positive for HIV
Kidney Problems
Nausea / Vomiting
Bowel / Bladder Disorders
Bed Wetting
Skin Abnormalities
Glaucoma
Obesity
Do you have, or have you had any of the following?
 YesNo
Sexual Dysfunction
Are you pregnant?
Lung Disease
Asthma / Breathing Difficulties
Cancer
Osteoporosis
Fractures/Broken Bones
Chronic Pain
Fibromyalgia
Rheumatoid/Osteo Arthritis
Sleep Apnea
Insomnia
Do you have, or have you or a family member had any of the following conditions?
 YesNoWho
Depression
ADHD
Bipolar
Schizophrenia
Anxiety
Post Traumatic Stress
Oppositional Disorder
Borderline Personality
Substance Use:
 Age/Year First UsedAge/Year Last UsedHow Often UsedHow Much Used
Alcohol
Caffeine
Cocaine
Marijuana
Methamphetamine
Nicotine
Prescription drugs abuse
Other
 YesNo
Have you ever been in substance abuse treatment?
Do you have, or have you had any of the following?
 YesNo
Have you ever thought you should cut down on your drinking of alcohol?
Has anyone every complained about your drinking?
Have you ever felt guilty or upset about your drinking?

Development/Education:

Social Background: