ࡱ> W fbjbjɺ 8أeأeZG%%%%%9998q49G*114eee )))))))$,.|,)%,)%%ee4* j%e%e) ) :B%,%e@,|:n% (*0G*x% G/G/%%G/%%\0" 1,),)XG*G/ : Piedmont Psychiatric Clinic - Form #3-2/2019 Dave M. Davis, M.D., D.L.F.A.P.A., D.L.F.A.B.F.P.,D.L. F.A.B.P.N. Annie M. Cooper, M.D., D.A.B.P.N. PERSONAL HISTORY QUESTIONNAIRE INSTRUCTIONS: This information is CONFIDENTIAL. The following information is very important to your health. Please take the time to answer these questions fully and accurately. If you do not wish to answer any questions, merely write OMIT. 1.PERSONAL INFORMATION: Last Name: ________________________First Name ___________________Middle Name___________ Age: ____Sex: ________ Preferred or Nick Name that you would like to go by: _______________________________________________________________ Marital Status: ____married ___ divorced ___ separated ___ common-law marriage ____living together ___never married ___spouse deceased ___number of marriages Education level (highest grade you completed): __________Occupation: _____________Number of children: ________ Name of Referring Physician or Agency: _________________________________________________________________________ Name and Specialty of Physicians/other Healthcare Providers you see regularly: __________________________________________ ___________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________________________________________________________________________%Please check here if you need to write additional Specialist / Physicians on page #10. List all Allergies and what type of reaction that you may have had to Medications or other Substances: Medication Type of Reaction Age at time of Reaction ______________________ ________________________________ ____________________ ______________________ ________________________________ ____________________ ______________________ ________________________________ ____________________ Please list any medicines you are currently taking or have taken during the past six months (including aspirin, birth control pills, hormone replacements or any other medicines that were prescribed or taken over the counter): Name of Medicine(s) Strength & Dosage Purpose Taken since (date) Prescribed by (how much do you take & how often do you take your medication(s) Example: Lipitor_________________ 20 MG-1 tablet - once a day Cholesterol____April 2001____ Dr. Jones___ 1.)________________________ _________________________ _____________________________ ____________ 2.)________________________ _________________________ _____________________________ ____________ 3.)________________________ _________________________ _____________________________ ____________ 4.)________________________ _________________________ _____________________________ ____________ %Please check here if you need to write additional medications on page #10 2.DESCRIPTION OF PRESENTING PROBLEMSState in your own words the nature of your main problems (why you came to see us): ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ On the scale below, please estimate the severity of your problem(s): Mildly Upsetting_____ Moderately Upsetting_____ Severe_______ Incapacitating______ When did your problems begin (give dates)? _______________________________________________________________ Please describe significant events occurring at that time, or since then, which may have contributed to the development or maintenance of your problems: ___________________________________________________________________________ _____________________________________________________________________________________________________ What solutions to your problems have you tried? ____________________________________________________________ _____________________________________________________________________________________________________ Have you been in therapy before or received any prior professional assistance for your problems? If yes, include marriage/sexual counseling, pastoral counseling, psychotherapy, and child/adolescent treatment, and / or family doctor: Treating Professional Profession Purpose Dates ___________________ ___________________ ________________________ ______________ ___________________ ___________________ ________________________ ______________ ___________________ ___________________ ________________________ ______________ %Please check here if you need to write additional Providers/Interventions, Etc. on page #10 List ALL psychiatric hospitalizations, residential, day care treatment or partial: Hospital Doctor Purpose Dates ___________________ ___________________ ________________________ ______________ ___________________ ___________________ ________________________ ______________ ___________________ ___________________ ________________________ ______________ %Please check here if you need to write additional Psychiatric/Providers/Interventions hospitalizations, Etc. on page #10 3.PERSONAL AND SOCIAL HISTORY Date of Birth: ______________ Place of Birth: _________________________ Adopted: ____Yes ____No SIBLINGS (including 1/2 siblings and step siblings): Number of brothers: __________ Name and Age of brothers: ________________________________________________________ Number of sisters: ____________ Name and Age of sisters: _________________________________________________________ FATHER: Living? __________ If alive, give fathers present age: ___________________ If deceased, give his age at time of death: ____________ How old were you at the time of his death? ___________ Cause of death: _____________________________ His occupation(s) past or present: ______________________Health: ____________________________________ MOTHER: Living? __________ If alive, give mothers present age: _________________ If deceased, give her age at time of death: ____________ How old were you at the time of her death? ___________ Cause of death: _____________________________ Her Occupation(s) past or present: ______________ Health: ___________________________________________ How strong a force was religion in your family life as a child? (Circle one) Very-strong Moderately-strong Mild Minimal None How strong a force is religion in your life now? (Circle one) Very strong Moderately-strong Mild Minimal None Circle any of the following that occurred during your childhood/adolescence. Then in the space provided, write your age at the time the event(s) occurred: ___Parental neglect ___Lack of Love ___Abandonment ___Financial Problems ___Happy Childhood ___Legal Trouble ___Physical Abuse ___Parental Remarriage ___Unhappy Childhood ___School Problems ___Medical Problems ___Frequent Moves ___Emotional/Behavior Problems ___Family Problems ___Parental Separation ___Parental Divorce ___Alcohol Abuse ___Drug Abuse ___Sexual Abuse ___Raised by someone else other than parents ___Others (specify): ______________________________ PERSONAL AND SOCIAL HISTORY(Continued....) What sort of work are you doing now? ______________________________________________________ Have you ever been fired from a job:_______Yes _______ No What kinds of jobs have you held in the past? ________________________________________________ _____________________________________________________________________________________ Does your present work satisfy you? _______Yes _______ No If not, please explain: ___________________________________________________________________ Military Service: Did you serve in the military as %Active | %Reservist or %National Guard? _______Yes _______ No Which Branch? %Air Force | %Army | %Coast Guards | %Marines | %Navy What is or was your Rank? _____________ List the dates of service: ______(enlisted) to ______ (discharge) Type of Discharge: %Honorable | %Medical | %Dishonorable Do you have other means of income such as alimony, pension, disability, etc.? _____________________ What is your height? _______ ft. _______ inches. What is your weight? ______________ lbs. Have you ever been hospitalized for psychological problems or addiction treatment? ______ Yes ______ No If yes, when and where? _______________________________________________________________ ___________________________________________________________________________________ Have you ever attempted suicide? _______Yes _______ No Have you ever had recurring thoughts of suicide? _______ Yes _______ No Is there any past or present history in your family (blood relatives) that suffer from alcoholism, depression, or anything else that might be considered a mental disorder? ____________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Has any relative attempted or committed suicide? __________________________________________________________________ 4.INTERPERSONAL RELATIONSHIPS Father: What was your father like to you? ________________________________________________________________________ How did he affect the way you felt about yourself? __________________________________________________________________ How is your relationship with your father now? ____________________________________________________________________ INTERPERSONAL RELATIONSHIPS (Continued....) Mother: What was your mother like to you? ______________________________________________________________________ How did she affect the way you felt about yourself? _________________________________________________________________ How is your relationship with your mother now? ___________________________________________________________________ How is your relationship with significant other figures (grandparents, step parents, etc.) in childhood? _______________________ __________________________________________________________________________________________________________ Were you ever bullied or severely teased? ________________________________________________________________________ Rate the degree to which you generally feel comfortable and relaxed in social situations: ______Very relaxed _______Relatively comfortable _______Relatively uncomfortable _______Very Anxious Were you ever sexually, physically, verbally, or emotionally abused? _________________________________________________ Generally, do you express your feelings, opinions, and wishes to others openly? _______ Yes _______ No If we need someone, other than yourself, to give us history or background information on you, whom may we contact? Name: __________________ Address: ___________________________ Phone number: Home)____________ Cell) _____________ 5. MARRIAGE OR PARTNERSHIP -If in Partnership consider as Spouse Number of Marriages ________ Divorces________ Death of Spouses ________ Current spouses / partners name:________________________________ How long did you know your spouse before your engagement? _______ How long have you been married? _______ What is your spouses age? ______ What is your spouses occupation? ___________________________________________ Describe your spouses personality: ________________________________________________________ How would your spouse describe you? _____________________________________________________ In what areas are you compatible? _________________________________________________________ In what areas are you incompatible? ________________________________________________________ How do you get along with your in-laws (this includes brothers and sisters-in-law)? _________________ Number of children: ___________________ Number of pregnancies: _________________ Number of Abortions: ___________________ Number of Miscarriages: _________________ Do you think there was, or may have been, inappropriate sexual behavior initiated toward you as a child? _______ Yes_______No ___________________________________________________________________________________________________________ MARRIAGE OR PARTNERSHIP -If in Partnership consider as Spouse (Continued.....) Have there been sexual relationships which you feel were damaging to you? ____________________________________________ Are there concerns presently in your life that relate to your sexuality or your present sexual relationship? ______________________ __________________________________________________________________________________________________________ 6. LIST YOUR THREE MAIN FEARS: (1)___________________________________________________________________________________ (2)___________________________________________________________________________________ (3)___________________________________________________________________________________ 7.PHYSICAL SENSATIONS: Circle any of the following that often apply to you: Headaches Stomach trouble Flushes Dont like being touched Dizziness Tics/twitches Skin problems Excessive sweating Palpitations Fatigue Dry mouth Visual disturbances Muscle spasms Back pain Chest pains Hearing problems Tension Tremors Burning/itchy skin Hear things Fainting spells Rapid heartbeat Tingling/Numbness Sexual Problems Blackouts Chronic Pain Sexually Transmitted disease Check any of the following stresses that have applied to you over the past 12 months: _______Divorce or separation _______ Problems with Parents _______Problems with money _______Having to care for aging relatives _______ Problems with children _______Problems with spouse _______Death of a close family member _______Son or daughter leaving home _______Problems with neighbors _______Personal illness or injury _______Trouble with in-laws _______Problems with Co-workers _______Marriage _______Change in residence _______Change in eating habits _______Changes in my work _______Change in sleeping habits _______Problems with sex _______Other: _________________________________________________________________________________________ 8.THOUGHTS What do you consider to be your most irrational thought or idea? ______________________________________________________ Are you bothered by thoughts that occur over and over again? _______ Yes _______ No ____________________________________________________________________________________________________________ 9.LEGAL | LIFESTYLE: Circle any that apply to you: Jailed Bankruptcy Been sued IRS problems Paternity suit Filed lawsuit Juvenile Court Arrests Workers Compensation Crime victim Disability Victim of violent crime Truancy DUI Suspended drivers license Conviction Prison Used illegal substance(s) Fired from job Fighting Carry a weapon Destroy property Animal cruelty Irresponsible parenting Child Abuse Fire setting Shoplifted/theft/stealing Rape Sexual harassment Pay Garnished Pornography Computer Addiction Excessive Phone/Text Use 10.HEALTH Do you eat three well-balanced meals each day? _______Yes _______No If not, please explain: __________________________________________________________________________________ Do you get regular physical exercise? _______Yes _______No If so, what type and how often? ________________ How much alcohol do you drink per week? ____________________________If you quit, when? ____________________________ How much tobacco do you use per week? _____________________________ If you quit, when? ___________________________ Do you use Energy Drinks or Stimulants? Yes _______ No _______ If you quit, when? ____________________________ Have you used recreation/illegal drugs? Yes _______ No _______ If yes, at what age(s)? ________________________ Describe ____________________________________________________________________________________________________ If you have quit, when? ________________________________________________________________________________________ HEALTH (Continued....) Do you have any current concerns about your physical health? Please specify: _____________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ A.) Have you had a Colonoscopy? _______Yes _______No _______Date of the last screening? B.) Have you had a Prostate Screening? _______Yes _______No _______Date of the last screening? C.) Have you had a Mammogram? _______Yes _______No _______Date of the last screening? Check your experience of the following: NeverRarelyFreq.OftenPrescription drugsNon-Prescription drugsAlcoholCoffeeCigarettesDiarrheaConstipationAllergiesHigh blood pressureHeart problemsVomitingInsomniaHeadachesBackacheSleep difficultiesProblems with eating List all major illnesses you have had and dates: ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ FOR WOMEN ONLY: Are your menstrual periods regular? ________________________________________________________________________ Do you have pain? ________________________________________________________________________________________ Do your periods affect your mood? __________________________________________________________________________ %Please check here if you need to write additional information on the reverse side of this page HEALTH (Continued....) Circle any of the following that apply to you: Thyroid disease Infectious diseases Prostate problems Kidney disease Gastrointestinal disease Asthma Cancer Epilepsy Neurological disease Blood disease Diabetes Glaucoma Gynecological Lung disease Sexually transmitted disease High Blood Pressure Other: ________________________________________________________________ ________________________________________________________________________________________ List ALL medical/surgical hospitalization(s): Treating Name of Hospital & Location (City/State) Reason for Hospitalization/Surgery Doctor Date _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ ____________________________________________________________________________________ _____________________________________________________________________________________________________ %Please check here if you need to write additional medical/surgical/hospitalizations on the reverse side of this page Have you ever had any head injuries or loss of consciousness? _______Yes _______No Please give details: _________________________________________________________________________________________ Please describe any accidents or injuries you have suffered (give dates): _______________________________________________ ___________________________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ &(+,-PT_vѮujfVGh%5CJOJQJ\aJh%5>*CJOJQJ\aJh +Fh%5OJQJ\h`5OJQJ\h I3CJaJh|CJaJhFqJCJaJh5CJaJh6Ah`5>*CJaJ% *h`h`5>*CJOJQJaJ *h '5>*CJOJQJaJ% *h6Ah`5>*CJOJQJaJh`56CJ$\]aJ$h?56CJ$\]aJ$- N / q W  [$\$gd[~dh[$\$gd[~dh[$\$gd@agd[~gd% [$\$gd$ [$\$gde$[$\$a$gd`gd5$a$gd` * k    . < ? 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