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What is your goal in seeking treatment?
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What is your primary complaint today?
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Please list all medications and dosages that you are on.
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Past Medical History
• • •
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Have you ever attended in-patient or out-patient rehab/detox?
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Is this visit court ordered?
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Have you ever been hospitalized or visited the ER due to a mental health concern
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Is this visit related to a disability claim?
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Is this visit related to a car accident?
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Is this visit related to a child protective services case?
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Loss of interest
• • •
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Feel 'on edge'
• • •
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No energy
• • •
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Hyperventilation
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Cry easily
• • •
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Fainting/Dizziness
• • •
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Can't concentrate
• • •
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Pounding heart
• • •
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Can't fall asleep
• • •
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Worrying too much
• • •
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Sleep too much
• • •
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Feel hopeless
• • •
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Feel sad
• • •
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Feel Fear or Anxiety Of:
• • •
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Restless
• • •
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Nausea
• • •
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Irritable mood
• • •
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Numbness/Tingling
• • •
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Thoughts of suicide
• • •
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Chest pain
• • •
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Fidgeting
• • •
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No need for sleep
• • •
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Racing thoughts
• • •
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Fear of going crazy
• • •
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Easily distracted
• • •
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Can't pay attention
• • •
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Overactive sexually
• • •
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Interrupts others
• • •
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Feeling numb
• • •
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Uncontrollable urges
• • •
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Nightmares
• • •
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Explosive temper
• • •
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Flashbacks
• • •
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Gambling too much
• • •
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Drinking too much
• • •
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Sexually abused
• • •
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Physically abused
• • •
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