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What is your goal in seeking treatment?
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What is your primary concern for wanting to be seen today?
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How long have you had this issue?
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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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