Microsoft word - behavioral health comprehensive history.wpd

Behavioral Health Comprehensive History Name___________________________________________ Date___________________ Check the best answer to each numbered symptom to indicate whether you have ever had problems related to it. In the past Currently Never Your feelings and moods
1. Depression ____ ____ ____ 2. Mood swings ____ ____ ____ 3. Nervousness ____ ____ ____ 4. Panic attacks ____ ____ ____ 5. Lack of motivation ____ ____ ____ 6. Anger ____ ____ ____ 7. Sadness ____ ____ ____ 8. Guilt or shame ____ ____ ____ 9. Feelings of impending doom ____ ____ ____ 10. Feelings easily hurt ____ ____ ____ 11. Feeling euphoric (high) or excessively energetic ____ ____ ____ 12. Irritability ____ ____ ____ 13. Restlessness ____ ____ ____ 14. Boredom ____ ____ ____ Please write comments if you would like to clarify any answers in this section. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Your thoughts In the past Currently Never
1. Hopelessness ____ ____ ____ 2. Worthlessness ____ ____ ____ 3. Wishing you were dead ____ ____ ____ 4. Hating yourself ____ ____ ____ 5. Thinking you are a bad person ____ ____ ____ 6. Thinking about killing yourself ____ ____ ____ 7. Planning how to kill yourself ____ ____ ____ 8. Believing people are out to get you ____ ____ ____ 9. Being confused ____ ____ ____ 10. Excessive worrying ____ ____ ____ 11. Hating another person ____ ____ ____ 12. Thinking about killing another person or people ____ ____ ____ 13. Having delusions ____ ____ ____ 14. Paranoia ____ ____ ____ 15. Having obsessions ____ ____ ____ 16. Phobias ____ ____ ____ 17. Obsessing about sex ____ ____ ____ 18. Hearing voices or sounds that others don=t hear ____ ____ ____ 19. Seeing things that others don=t see ____ ____ ____ 20. Excessively worrying about your health ____ ____ ____ 21. Thinking you have let yourself down ____ ____ ____ 22. Thinking you have let others down ____ ____ ____ Please write comments if you would like to clarify any answers in this section. ______________________________________________________________________________
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How you feel physically In the past Currently Never
1. Lack of energy ____ ____ ____ 2. Poor appetite ____ ____ ____ 3. Poor sleep ____ ____ ____ 4. Disturbing dreams ____ ____ ____ 5. Excessive sleep ____ ____ ____ 6. Frequent headaches ____ ____ ____ 7. Sex drive diminished or absent ____ ____ ____ 8. Overweight ____ ____ ____ 9. Frequent or constant pain ____ ____ ____ 10. Chronic illness ____ ____ ____ 11. Physical disability ____ ____ ____ 12. Female problems ____ ____ ____ 13. Frequent indigestion ____ ____ ____ Please write comments if you would like to clarify any answers in this section. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Your behavior
1. Difficulty with the daily routine ____ ____ ____ 2. Anger outbursts ____ ____ ____ 3. Driving aggressively ____ ____ ____ 4. Isolating yourself from others ____ ____ ____ 5. Overeating ____ ____ ____ 6. Overspending money ____ ____ ____ 7. Drinking alcohol to excess ____ ____ ____ 8. Using drugs ____ ____ ____ 9. Getting arrested ____ ____ ____ 10. Biting nails, pulling hair, or picking at your skin ____ ____ ____ 11. Cutting or other self-injurious behavior ____ ____ ____ 12. Hitting people or abusing animals ____ ____ ____ 13. Attempting to control your weight through inducing vomiting, abusing laxatives, or exercising to excess ____ ____ ____ 14. Restricting food intake ____ ____ ____ 15. Gambling excessively ____ ____ ____ 16. Spending too much time on the computer ____ ____ ____ 17. Engaging in other compulsive behaviors ____ ____ ____ 18. Sexual compulsivity ____ ____ ____ 19. Attempts at suicide ____ ____ ____ 20. Unable to concentrate ____ ____ ____ 21. Memory problems ____ ____ ____ 22. Unable to get organized ____ ____ ____ 23. Unable to make or maintain friendships ____ ____ ____ 24. Getting into fights ____ ____ ____ Please write comments if you would like to clarify any answers in this section. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Your experience at work In the past Currently Never
1. Performing below your expectations or abilities ____ ____ ____ 2. Unhappy at work ____ ____ ____ 3. Frequently late ____ ____ ____ 4. Frequently absent ____ ____ ____ 5. Poor relationship with your boss ____ ____ ____ 6. Poor relationships with coworkers ____ ____ ____ 7. Find work boring ____ ____ ____ 8. Feel unappreciated ____ ____ ____ 9. Feel overworked ____ ____ ____ 10. Feel underpaid ____ ____ ____ 11. Feel insecure in your job ____ ____ ____ 12. Unemployment ____ ____ ____ 13. Military service ____ ____ ____ 14. Public safety employment ____ ____ ____ Please write comments if you would like to clarify any answers in this section. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Your personal life In the past Currently Never
1. Death of friend or family member (including pets) ____ ____ ____ 2. Financial problems ____ ____ ____ 3. Conflict with your spouse or domestic partner ____ ____ ____ 4. Relationship conflict ____ ____ ____ 5. Conflict with former spouse ____ ____ ____ 6. Victim of stalking or harassment ____ ____ ____ 7. Conflict with your father ____ ____ ____ 8. Conflict with your mother ____ ____ ____ 9. Conflict with your children ____ ____ ____ 10. Conflict with other relatives ____ ____ ____ 11. Unsatisfactory housing ____ ____ ____ 12. Law suit ____ ____ ____ 13. Involvement with the criminal justice system ____ ____ ____ 14. Not enough time for yourself ____ ____ ____ 15. Too much time on your hands ____ ____ ____ 16. Illness in the family ____ ____ ____ 17. Addiction in the family ____ ____ ____ 18. Other behavioral problems in the family ____ ____ ____ 19. Other legal problems in the family ____ ____ ____ 20. Sexual orientation issues ____ ____ ____ 21. Religious or spiritual conflicts ____ ____ ____ Please write comments if you would like to clarify any answers in this section. ____________________________________________________________________________________________________________________________________________________________ ______________________________________________________________________________
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Your family history
These questions apply to your blood relatives - Check all those that apply Is there any family history of the following? 1. Depression ____ 2. Excessive anxiety ____ 3. Alcohol abuse ____ 4. Drug abuse ____ 5. Psychiatric hospitalization ____ 6. Suicide or attempt at suicide ____ 7. Hyperactivity ____ 8. Problems with attention or concentration ____ 9. Eating disorder ____ 10. Violent behavior ____ Please write comments if you would like to clarify any answers in this section. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Your history of drug and alcohol use
Check all appropriate columns for each drug or substance mentioned Never used Past use Past abuse Current use Current abuse 1. Alcohol ____ ____ ____ ____ ____
2. Marijuana ____ ____ ____ ____ ____
3. Cocaine ____ ____ ____ ____ ____
4. Methamphetamine ____ ____ ____ ____ ____
5. Heroin ____ ____ ____ ____ ____
6. Prescription opiates (for
example, Oxycodone, Talwin,
Hydrocodone, Morphine, codeine,
Darvon, Ultram, Dilaudid,
Fentanyl, Buprenorphine) ____ ____ ____ ____ ____
Page 6 Never used Past use Past abuse Current use Current abuse 7. Tranquilizers (for example, Xanax, Ativan, Klonopin, Valium, Librium) ____ ____ ____ ____ ____ 8. Hallucinogenics (for example, LSD, mescaline, mushrooms) ____ ____ ____ ____ ____ 9. Party drugs (for example, Ecstasy, GHB, Roofies) ____ ____ ____ ____ ____ 10. Anabolic steroids ____ ____ ____ ____ ____ 11. Sleeping pills (for example, Barbiturates, Quaalude, Ambien) ____ ____ ____ ____ ____ 12. Inhalants (for example, hair spray, gasoline, solvents) ____ ____ ____ ____ ____ 13. Muscle relaxants (Soma, Robaxin, others) ____ ____ ____ ____ ____ 14. Others not mentioned above ____ ____ ____ ____ ____ Please write comments if you would like to clarify any answers in this section. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Have you ever had a head injury with or without loss of consciousness? Yes___ No___. If yes, please give details_______________________________________________________________ ____________________________________________________________________________________________________________________________________________________________ Have you ever been physically, sexually, or emotionally abused? Yes___ No___. If yes, please give details (if you are uncomfortable writing about this, this question can be explored at the time of the clinical interview.)_________________________________________________________ ____________________________________________________________________________________________________________________________________________________________ Has there recently been or do you anticipate a major change in your life circumstances, or are you faced with a major life decision at this time? Yes___ No___. If yes, please give details_______ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Is there a firearm in your home, or do you have access to one otherwise? Yes ___ No ___. If yes, please give details.___________________________________________________________ Have the police or the Department of Family and Children=s Services been to your home within the past year? Yes ___ No ___. If yes, please give details_______________________________ ____________________________________________________________________________________________________________________________________________________________ Is physical or sexual abuse a current problem in your home? Yes ___ No ___. If yes, please give details.________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________ Has physical or sexual abuse occurred in your home within the past year? Yes ___ No ___. If yes, please give details.___________________________________________________________ ____________________________________________________________________________________________________________________________________________________________ Your psychiatric treatment history
1. Please list, including dates and reasons, all past psychiatric hospital or detox center admissions. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 2. Other than the above, please list the names of all psychiatrists and other mental health professionals that you have seen, including the reason for treatment and approximate dates. Please include marriage or family counseling in this list, if applicable. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 3. Please indicate, if you have been treated with medication for a psychiatric disorder in the past, the name of the medication, side effects you may have experienced, whether the medication was helpful, and approximate dates of use. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 4. If you have ever participated in an out-patient therapy group, please indicate the therapist, approximate dates, reason for joining the group, and whether or not it was helpful. ____________________________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________________________ 5. If you have ever participated in a 12-step mutual help group, please indicate which group (AA, Al-Anon, GA, NA, etc.) you attended, whether it was helpful, and the approximate dates. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 6. If there is anything else in your mental health history that you would like to mention, please indicate it here. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 7. Please indicate below, in your own words, why you are seeking a mental health/substance abuse evaluation and/or treatment at this time. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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