To Help Us Serve You Better, Please Complete the Following Questionnaire and Return In

To help us serve you better, please complete the following questionnaire and return in the envelope provided. This information will help us better meet your needs. To contact the hospital Social Work Department, call:______

Patient name:______DOB:______Date:______

Best phone number to reach you (work)______

(home)______(cell)______

Email______

PERSONAL

Marital Status: Single Committed Relationship Married Separated Divorced Widowed

Length of Marriage/Committed Relationship:______Name of Significant Other:______

Current Member(s) of Your Household:______

Please indicate if your parents are living or deceased. Mother______Father______

Please indicate number of siblings. Sister(s)______Brother(s)______

If you have children, please list them below:

NAMEAGEM/FCITY/STATE

______

______

______

______

______

Please tell us about any other family members, friends, or work colleagues that play an important role in supporting your treatment. ______

______

EDUCATION & EMPLOYMENT

Please circle your highest level of education:

Less than 12th grade High School/GED Some College College Degree Post Graduate Degree Vocational Training Other

Please circle your current employment status:

Not Employed Retired Disabled Part-time Full-time Stay at Home Parent Student

What type of work do/did you do?______

FINANCIAL

Please indicate if you have applied for disability:

Short-termLong-termSocial Security Disability

Please list any financial concerns you may have at this time. ______

INTERESTS & HOBBIES

What do you enjoy doing in your leisure time?______

What do you have planned to pass time while in the hospital? ______

COPING

What are some things you do to cope with the stress of your illness and treatment?

______

Are you comfortable with the ways in which you are coping at this time? Yes No

If no, please explain______

Is spirituality a source of support for you? Yes No If Yes, do you affiliate with a specific religion or denomination?______

Have you ever attended a support group? Yes No

If yes, please tell us about your experience______

What concerns do you have about how your children or family members are coping with your illness and treatment? ______

Please rate your feelings of anxiety about treatment? None 1 2 3 4 5 6 7 8 9 10 Extreme

Please rate your feelings of depression about treatment? None 1 2 3 4 5 6 7 8 9 10 Extreme

Are you currently being treated for any mental health needs? Yes No If yes, please indicate method(s) of treatment: Medication Individual Therapy Family Therapy Couples Therapy Other______

Have you been treated in the past for any mental health needs? Yes No If yes, what were you treated for and what methods of treatment were used?______

If you are currently taking medication to address a mental health issue, please list:

Medication(s)______Dosage(s)______Prescribing Physician______

Have you ever experienced/witnessed any violence or abuse? Yes No If yes, please explain further if you are comfortable doing so______

HABITS

SubstanceSpecific TypeFrequency of UseAmount used Per day/Per week

Tobacco______

Caffeine______

Alcohol______

MarijuanaN/A______

Other Drugs______

ADVANCE DIRECTIVES

Do you have a living will? Yes No

Do you have a durable power of attorney (health care power of attorney)? Yes No

If you wish, a copy of these documents can be kept on file with the hospital..

COMPLEMENTARY THERAPIES

Are you utilizing any complementary therapies at this time (herbs, relaxation techniques, etc.)? Yes No

If yes, please describe______

OTHER NEEDS

Please list any agencies where you currently receive services______

Are you registered with Leukemia and Lymphoma Society Patient Financial Aid Program? Yes No

If you live 60 minutes or more from the hospital, do you need assistance with arranging lodging during your treatment? Yes No

Please list any other information you would like us to know about you or any questions you may have.

______

______

THANK YOU!