Background Information Sheet

YOUR FAMILY CLINIC

PATIENT BACKGROUND INFORMATION SHEET

(PRIVACY ACT OF 1974 APPLIES WHEN FILLED OUT) Last revised: 20 July 10

Date: /

GENERAL INFORMATION

Medical Record Available? Y N
Name: (Last, First, MI) / Gender (circle one): Ethnicity:
M F ______/ Family Member Prefix:
(30,31,01,02,etc.)
Sponsor’s Name: / Sponsor’s Rank/Grade: / Sponsor’s SSAN:
Address: / City: / State: / Zip Code:
Age: / DOB: (dd-mmm-yy) / Duty / Work Phone: / Home Phone:
Military Member Information / Branch of Service: USN USAF
USA USMC USCG / Duty Title: / Flying Status: Yes No
Submarine Duty: Yes No
Status of military member: Active Duty Reserves Retired / Special duty program clearances: TS/SCI PRP PS
Relationship of patient to military member: Self Spouse Child Dependent Parent
Military member’s unit: / Name of Primary Care Manager (PCM):

IF YOU ARE NOT THE ACTIVE DUTY MEMBER, SKIP TO NEXT SHADED SECTION

Shift Work?
Yes No / Days per year TAD? / Ever deployed in combat?
Yes No / Supervisor’s name and number:
Month/Year of service entry: / Time on Station: / End of Enlistment: / Last 5 performance reports:
Two previous assignments and time at each:
Describe any work-related difficulties you may be experiencing. / Provider Comments:
Describe any past/pending disciplinary actions (e.g., Written Counseling, Article 15).
List any performance awards you have been given.
Information About Your Primary Concern or Problem
Please note any concerns you may have about privacy or your rights: / Provider Comments:
Limits to confidentiality discussed? Yes No
Patient agreed? Yes No
Patient confirmed voluntary? Yes No
Please describe the primary concern/problem for which you have come to our clinic.
How long have you been experiencing this concern / problem?
Is this visit related to a previous deployment? Yes No
Have you been directed to come here by your CO or supervisor? Yes No
Do you consider yourself to be here voluntarily? Yes No
Who referred you to Behavioral Health?
What led to your decision to seek help now?
Circle the word below that best expresses the impact of your problems on your life:
None Mild Moderate Severe Very Severe
Have you had difficulties or troubles similar to this before? Please describe:
What solutions, if any, were most helpful in resolving these difficulties / troubles? / Provider Comments:
Psychological Functioning
How would you describe your mood during the past week? (circle all that apply)
Depressed Anxious Irritable Sad Tense Happy Good Hopeless Helpless Other:
Are you feeling helpless or hopeless at the present time? / Yes / No / Provider Comments:
Over the past two weeks:
**Have you had thoughts of suicide? / Yes / No
**Have you had thoughts of hurting someone else? / Yes / No
Have you ever intentionally tried to hurt or kill yourself? / Yes / No
Has anyone close to you ever attempted or completed suicide? / Yes / No
Have you recently engaged in any impulsive or dangerous activities? / Yes / No
Has your mood ever been down or depressed for more than two weeks? / Yes / No
Do you believe that you have had unhealthy or uncontrollable mood swings? / Yes / No
Do you feel others are out to get you or are trying to harm or control you? / Yes / No
Have you ever had an anxiety attack that felt like you lost control physically? / Yes / No
Have you ever been afraid of a specific object or situation (e.g., heights, water) / Yes / No
Have you ever been afraid to speak or perform in public? / Yes / No
Do you have any repetitive thoughts that don’t seem to stop? / Yes / No
Do you tend to worry yourself sick? (e.g., headaches, stomach pain, etc.) / Yes / No
Have you experienced any situation in which you or someone else could have been killed or severely injured? (e.g., bad car accident, combat, rape/molestation, etc.) Please describe: / Yes / No
Have felt disorganized and easily distracted throughout your life? / Yes / No
Over the past week:
---Have you noticed a change/problems with your sleep? / Yes / No / S
---Have you noticed a loss of interest in pleasurable activities? / Yes / No / I
---Have you experienced guilt about anything in your life? / Yes / No / G
---Have you noticed a change in your energy level? / Yes / No / E
---Have you noticed any changes or problems with concentration? / Yes / No / C
---Have you noticed any changes or problems with your appetite? / Yes / No / A
---Have you felt physically or mentally slowed down or sped up? / Yes / No / P
Alcohol Use
On average, how many times do you usually drink in a week? (circle which applies)
Don’t drink Less than 1 2 3-4 4-5 5-7 More than 7 / Provider Comments:
On average how many drinks do you consume when you drink? (circle which applies)
Don’t drink Less than 1 1-2 3-4 5-6 7-9 10 or more
When was the last time you drank and how much? / ETOH related incidents? Yes No
Has there been an increase in the amount of your drinking over the past six months? / Yes / No / Provider Comments
Have you recently felt you should cut down on the your drinking? / Yes / No / C:
Have you ever felt annoyed by people criticizing your drinking? / Yes / No / A:
Have you ever felt guilty or bad about your drinking? / Yes / No / G:
Have you ever drunk to relieve a hangover or to calm your nerves? / Yes / No / E:
Have you had any physical, work, or relationship problems as a result of drinking? / Yes / No
Have you driven after drinking more than 2 drinks? / Yes / No
Have you had any legal problems related to drinking? (e.g., DUI, DWI, public intoxication, etc) / Yes / No

Other Habits

Type

How much

Frequency/duration of use

When last used

Provider Comments:

Tobacco (e.g., cigarettes, cigars, pipe, chew)

Drugs (e.g., marijuana, cocaine, heroin, inhalants, etc)

Caffeine(e.g., coffee, tea, sodas or soft drinks, chocolate)

Please circle any other habits you have: Gambling Over/undereating or exercising Pornography/sexual problems
Arranging/rearranging Excessive shopping/spending Checking or counting Other repetitive behavior:
Do you wish to receive assistance with nutritional needs?
If yes, please explain your current dietary habits: /

Yes

No

Do you wish to have assistance with smoking cessation?

Yes

Mental Health And Substance Abuse Treatment History
Have you received counseling / therapy or other mental health /substance abuse treatment? If so, please describe: / Yes / No
If “yes,” were you hospitalized? Please describe: / Yes / No
Are you currently in treatment? If so, what is the name of your provider? / Yes / No
Have you ever been prescribed medication(s) to change your mood, thoughts, behavior or sleep? If so, which medications? / Yes / No
Does anyone in your family (parents, siblings, grandparents, uncles, aunts) have a history of alcoholism, depression, or any other condition that might be considered a mental health disorder /condition?
If “Yes,” please explain: / Yes / No
Medical History
Are you experiencing any medical problems right now? If yes, what are they?
Have you had any adverse drug reactions?
Do you have any food or drug allergies? / Provider Comments:
TBI: LOC: Seizures:
Have you received medical care for these problems?
What medications are you taking for these problems?
Are you taking any other medications (prescription, over the counter, herbal or otherwise)?
Are you experiencing any physical pain? No Yes Where?
On a scale from 1 to 10 (10 being the worse pain imaginable), rate your present pain.
1 2 3 4 5 6 7 8 9 10
Have you received medical attention? Yes No Would you like a medical referral?

Personal & Social History

Were you adopted? Yes No / Number in birth order (please circle)
1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th
Number of siblings: / Where were you raised? / Birth Place:
Are your parents divorced? Yes No If so, when? With whom did you live?
Parent (s)
Occupation and Educational level / Father:
Stepfather: / Mother:
Stepmother:
Did you experience any difficult family problems duringchildhood or adolescence? (e.g., death of parent, physical/emotional/sexual abuse, divorce, persistent medical problems, poverty, drug problems in family, etc.) Please describe: / Provider Comments:
Hx: PA SA EA Assault
Have you experienced any severely stressful situations as anadult? (e.g., domestic violence, divorce, abuse, legal problems, unmanageable debt, etc.) Please describe:
Do you currently live alone? / Yes / No / Provider Comments:
Are things at home going alright? / Yes / No
Are you geographically separated from your family or friends? / Yes / No
Who do you prefer to confide in?
Have you recently withdrawn from friends and family and become more isolated? / Yes / No
Are you in any groups or organizations that are supportive to you? Please describe: / Yes / No
Within the last year, have you been hit, kicked, punched, or otherwise hurt by someone else? / Yes / No
Is anyone in your life making you feel unsafe in any way? / Yes / No
Please list any abusive relationships that you may have been involved in (e.g., family, partner, etc.) / Yes / No / FAP required? Y N

Immediate Family

Name of spouse or partner:

How long have you been married/in a relationship? __What is your spouse’s/partner’s age?_

Do you have concerns about your physical relationship with your partner?______

How would you rate your overall satisfaction with the relationship?

1 2 3 4 5

Very unsatisfied Unsatisfied Neutral Satisfied Very satisfied

What problems do you have in your relationship?

What strengths do you have in your relationship?

If you have any children, please complete the following:

Name: Age: Gender: Living at Home?
______M F Y N
______M F Y N
______M F Y N
______M F Y N

______M F Y N

Spiritual History

Do you have any continuing involvement in religious or spiritual activities? If so, what is your religious/spiritual affiliation?

Yes

How much is your religion/spirituality a source of strength and comfort to you?

___ Not at all ___ Not very much ___ Some ___ Quite a bit ___ A great deal

Are you satisfied with the spiritual dimension of your life?

Yes

Have you been talking individually to a chaplain or minister about the problems that are bothering you?

Yes

Do you have any religious/cultural practices that may affect your care or limit your learning? If yes, please explain: /

Yes

Educational History

What is the highest level/grade of schooling you have completed? / Typical grades? / Provider Comments:
Do you have a history of a learning disability, trouble reading, being identified as gifted, or any other special educational need?
Yes No If yes, explain:
Was there a subject in school that gave you particular problems?
Please describe any behavioral problems you may have had during school (e.g., fighting, etc) / Barriers to learning or communication?
Yes No

BOX BELOW IS FOR PROVIDER USE ONLY

Mental Status Examination: Ptappearance: appropriately, poorly, well, groomed. Other: ______Psychomotor activity: WNL, other: ______
Agitation: none, mild, moderate, marked severity Orientation X 4, other: ______Level of Consciousness: alert, clouded, confused, other: ______Cooperation: cooperative, guarded, interested, uncooperative, suspicious, other: ______Speech: WNL, articulate, slurred, loud, soft, rapid, slow, pressured other: ____
Thought Processes: organized, coherent, disorganized, incoherent, other: ______Thought Content: congruent, obsessive, delusional, preoccupied ______
Hallucinations: Y N Delusions: Y N Memoryimpairment: none, recent, remote Attention: Excellent Good Fair Poor
Judgment: Excellent Good Fair Poor Insight: Excellent Good Fair Poor Impulsivity: none behavioral emotional other:______
Mood: euthymic, dysphoric, euphoric, despairing, irritable, angry, depressed, anxious, fearful, other: ______Emotional Reliability: Excellent Good Fair Poor
Affect: appropriate to mood, inappropriate to mood, full range, restricted, constricted, labile, flattened, other: ______Homicidal ideation/plan/intent? ______
___Suicidal ideation ___Intent ___Method determined ___Means available Specific plan:______Frequency of ideation:____ Duration of Ideation:____
___ Previous Attempts (#, age, method) ___ Lethality of Means ___ Caucasian ___ Age >45 / <20 ___ ETOH Dependence ___ Major Depression (hopelessness) ___ Major Loss ___ Chronic Medical Illness
___ Rational Thinking Loss ___ Lack of Social Support ___ Male ___Hx of suicidal behavior ___Family member suicide ___Combat Trauma ___Other Trauma ___Hx of abuse ___ Chronic Pain
___Wish to die ___Expectancy of attempt ___ Lack of deterrents to attempt ___ Talk of death or suicide ___Courage to make attempt ___Competence to make attempt ___ Preparations to make an attempt
___ Severe Legal/Financial Problems ___ Significant Agitation ___Severe Mood Swings ___ Multiple attempter ___Substance Abuse/Dependence Add to high risk list? Yes No
Deterrants to suicide/homicide: ___ Fear of hurting loved ones ___Religious Convictions ___Future goals pending Other:______
SUICIDE RISK LEVEL: No significant risk Mild Moderate Severe Extreme CRP completed with patient? Yes No N/A

Treatment Goals

Your Family Clinic LLC offers a variety of treatment programs and approaches. To offer you the treatment opportunities most in line with your reasons for coming to the clinic, please check (√) any of the following goals that interest you.

1. Discussing my thoughts of harming myself / 27. Talking out a pending decision
2. Discussing my thoughts of harming others / 28. Improving my sleep
3. Improving my communication with my:
_____ spouse/children
_____ parents
_____ friends/co-workers / 29. Reducing family difficulties (specify):
______
4. Worrying less about: ______/ 30. Better manage my temper
5. Learning how to relax / 31. Feeling less guilty
6. Learning stress management skills / 32. Receiving medication assistance/information
7. Better managing my health (specify): ______/ 33. Learning problem-solving & decision making skills
8. Changing my habit of: ______
______/ 34. Adopting to a more healthy attitude about: ____
______
9. Feeling less depressed/sad / 35. Expressing myself more assertively
10. Feeling less anxious / 36. Decreasing procrastination
11. Reducing my sensitivity to possible criticism / 37. Better managing my time
12. Learning how I come across to others / 38. Taking the initiative more often
13. Not taking disappointments so hard / 39. Not reacting so emotionally
14. Doubting myself less / 40. Allowing myself to express feelings more
15. Thinking more positively / 41. Feeling more self-confident
16. Improving my marriage or relationship / 42. Reducing my fear of: ______
17. Controlling my eating/weight / 43. Having more pleasant activities
18. Better accepting the loss/death of: ______/ 44. Learning more effective parenting skills
19. Controlling my alcohol use / 45. Improving my self-awareness
20. Better management of my pain (specify location): ______/ 46. Adjusting better to a recent change/incident (specify): ______
21. Learning how to improve my friendships / 47. Reducing job difficulties
22. Reducing uncomfortable thoughts of: ______
______/ 48. Adjusting better to a past incident (specify): ___
______
23. Discussing a hardship discharge/humanitarian reassignment application / 49. Discussing my desire for a discharge/cross-training
24. Decreasing attempts to be perfect / 50. Increasing my social support
25. Better tolerating my mistakes / 51. Other (specify):
26. Better tolerating others’ mistakes / 52. Other (specify):
Now please review your list and decide which THREE goals you most wish to discuss/change at this time. GOAL # 1 _____ GOAL # 2 _____ GOAL # 3 _____

Section below is for provider use only

PROViDER COMMENTS: Concur with patient tx goals? Yes No Additional Goals:

1.
2.
3.
See AHLTA documentation for diagnosis and treatment plan.
WWQ: yes no Restricted Duty: yes no Contraindications to TS/SCI/PRP/PS/Flying? Yes No
AHLTA Entry submitted? Yes No
Additional SF-600 Attached? Yes No
Provider stamp/signature: