Name______Date______
Shaaring information about yourself will help me understand why you are here. Please answer the following questions before your first appointment. Thank you.
Name:______Date of Birth______Age______
Telephonew numbers ______
Address ______
1. What are the main concerns you have for seeking help at this time? Please include your symptoms, pain, illness, injuries, onset, upsets, losses, functional problems, fears, worries, etc.
______
______
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______
2. Please describe what you feel in your body and mark on the chart where you feel your symptoms.
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3. What would you like to achieve from therapy (what are your goals)? Include Functional Goals.
1.______
2. ______
3.______
4.______
4. List the medications, supplements, remedies and herbs you take.
______
______
______
5. Do you have any allergies?Yes___No___
6. Trauma and Medical History (include dates)
Include major illnesses, surgeries, hospitalizations, accidents, injuries and traumas.
______
______
______
______
______
7. Primary Care Provider______Phone ______
8. Do you exerciseYes____No____
What do you do, how often and how much?______
9. Do you have a spiritual practice?Yes____No____
What is it?______
10. Do you smoke tobacco?Yes____No____Cigarette, Cigar, Pipe
How many per day______
Did you ever smoke tobacco?Yes____No____
When did you quite______How much did you smoke______
11. How much alcohol do you drink, if any?None____
___beers/day____glasses of wine/day____drinks/day
12. Do you use recreational drugs? Yes____No____
If yes, what do you use?______
How often?______
13. What are you eating habits like?
Typical breakfast______
Typical Lunch______
Typical Dinner______
Typical Snacks______
14. Have you every had a problem with eating or an eating disorder?
Yes____No____Anorexia, Bulimia, Binging, Overeating
15. How is your sleep?______
______
16. Do you remember your dreams?Yes____No____
Has there been a theme to them recently? What is it?______
______
17a. What are the stressors in your life right now?______
______
17b. How do you reduce your stress?______
______
18. Hove you experienced any anxiety or depression lately?
Anxiety____Depression____Mixed____
Please describe:______
______
19. Have you recently or in the past thought about suicide?Yes____When____No___
Have you ever attempted suicide?Yes____No____
If your answer is yes to either of these questions, please describe what treatment
have had:______
______
20. What do you do that makes you feel good?______
______
21. Have you ever been, or are you presently in counseling or psychotherapy?
Yes____No____Other therapeutic work____
Describe why you went and your experience:______
______
22. Have you been treated for any ongoing medical problems?
Yes____No____Please describe:______
23. What is your occupation?______
Do you enjoy your work?Yes____No____
Describe why or why not:______
______
24. What kind of support system do you have?
Family____Friends____Relative____Other______
25. Marital status:
Single____ Married____Spouse’s Name______
Divorced____Remarried____ Committed Relationship ___
If divorced, when did you get divorced?______
How was the process?______
If remarried, when did you get remarried?______
Do you have a blended family?Yes____No____
How many children?Yours____Spouses____Together____
26. Your children:
NamesAgesLiving Where?
______
______
______
27. Family History
NameAgeAge @ DeathIllnesses (med/psych)
Mother______
Father______
Sisters______
______
______
Brothers______
______
______
28. Briefly describe your childhood, particularly in relationship to your family of origin
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______
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29. Sexual Orientation: Straight____ Gay____ Lesbian____ Bisexual____
30. Briefly describe your present living situation:______
______
______
31. What is you level of education?______
32. What do you enjoy doing in your life?______
______
Is there anything else you would like me to know right now?
Thank you for taking the time to reflect on aspects of your life and completing this form.