Psychiatry Associates, P.C.
1736 Oxmoor Road. Suite 103
Birmingham, AL 35209
Telephone: 879 2120. Telecopier: 879 2125
PATIENT QUESTIONNAIRE
______________________________________________________________________________________
Full name ______________________________________________________ Date: ________________
Male; Female Birthdate __________ Marital status __________ Age ________ Race ________
Address __________________________________________________Home phone _________________
Occupation _______________________________________________ Mobile phone __________________
Other significant contact_________________________________________ Phone __________________
Referred by _______________________________________________Relation ______________________
YOUR CURRENT CLINICAL PROBLEMS
List problems for which evaluation is sought: Length of time
1. ______________________________________________________________ _______________
2. ______________________________________________________________ _______________
3. ______________________________________________________________ _______________
4. ______________________________________________________________ _______________
5. ______________________________________________________________ _______________
6. ______________________________________________________________ _______________
Impairment associated with current problems:
Not at all A little bit Moderately Quite a bit Extremely
1. Work / School
2. Social life
3. Daily activities
What have you tried so far to correct these problems (changes in life, psychotherapy, drugs)?
______________________________________________________________________________________
______________________________________________________________________________________
What specific event(s) caused you to seek help at this time? ______________________________________
______________________________________________________________________________________
List all clinicians that have evaluated or treated you: None
Clinician Reason Type of treatment Year and length
1.
2.
3.
4.
List prescribed and non-prescribed medications you are presently taking: None
Medication Reason Dosage Length of treatment
1.
2.
3.
4.
5.
YOUR PRESENT LIFE
Partner’s or spouse’s name ________________________________________ Years together ________
Age _________ Education _________________________ Occupation ___________________________
General relationship with partner or spouse ___________________________________________________
Physical or emotional problems _____________________________________________________________
List all persons living in the household with you:
Name Age Relationship Education Occupation
1.
2.
3.
4.
5.
Please check all events that may have occurred within the past 12 months:
Significant marital conflicts Marriage
Separation Pregnancy
Divorce Birth of child
Spouse with emotional difficulties Gain of new family member
Death of spouse Child leaving home
Psychiatry Associates, PC: Patient Questionnaire - Rev Feb, 2011. Page 2 of 6
Death of close family member Significant conflicts at work
Death of close friend Losing job
Personal injury or illness Change in job
Change in financial status Legal problems
Change in residence Other stress __________________________
Leisure and recreational activities ___________________________________________________________
Religious affiliation and practice ____________________________________________________________
Do you have any legal problems? No Yes. Explain _________________________________________
YOUR FAMILY
Mother’s full name _____________________________________________________________________
Age _________ Education ________________________ Occupation ____________________________
General relationship with mother ___________________________________________________________
Health problems or cause of death __________________________________________________________
Father’s full name ______________________________________________________________________
Age _________ Education ________________________ Occupation ____________________________
General relationship with father ____________________________________________________________
Health problems or cause of death __________________________________________________________
Brothers and sisters:
Name Age Education Occupation Relationship
1.
2.
3.
4.
Check if any natural parent, brother, sister, uncle, aunt, cousin or grandparent has:
Attention deficit/hyperactivity disorder Problems with anxiety or panic attacks
Learning disabilities Addictions (alcohol, drugs, gambling, sex)
Mental retardation Schizophrenia
“Blues”, depressions Other psychiatric problem
Attempted suicide Tics, seizures or neurological problems
Bipolar/Manic depressive illness Legal problems
Please describe and indicate relation ________________________________________________________
Psychiatry Associates, PC: Patient Questionnaire - Rev Feb, 2011. Page 3 of 6
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YOUR LIFE STORY
Were there any problems with your mother’s pregnancy or delivery of you? No Yes
Explain _______________________________________________________________________________
Were you born full term? Yes No. Mother’s age when you were born _____________
Did you experience any separations from your parents as a child? No Yes. Explain _______
______________________________________________________________________________________
What were you like as a child?
Affectionate Very sensitive Irritable Moody
Content Distractible Overly active Aggressive
Fearful Playful Fussy / cranky Shy
Physically sick Quiet Nervous Obedient
Have you ever experienced verbal / physical abuse? No Yes. Explain ____________________
______________________________________________________________________________________
Have you ever experienced sexual abuse? No Yes. Explain ___________________________
______________________________________________________________________________________
What were you like during adolescence?
Confident Shy Overly active Happy
Sociable Aggressive Forgetful Defiant
Irritable Peaceful Explosive Responsible
Rebellious Depressed Unconventional Moody
List some good things about you. What can you do well? Special talents? ___________________________
______________________________________________________________________________________
How old were you when you first had sex? _________ How many sexual partners have you had? ________
Any sexual issues ? No Yes. Explain ______________________________________________
______________________________________________________________________________________
Have you been married more than once? No Yes. Explain ___________________________
______________________________________________________________________________________
______________________________________________________________________________________
Psychiatry Associates, PC: Patient Questionnaire - Rev Feb, 2011. Page 4 of 6
List all children residing away from home or deceased:
Name Age Education Occupation Relationship
1.
2.
3.
4.
YOUR PHYSICAL HEALTH AND HABITS
Your physician or family doctor ________________________________ ___ Phone ___________________
Are you allergic to medication or anything? No Yes. Explain _____________________
______________________________________________________________________________________
List all physical problems presently under treatment or observation: Length of time
1. __________________________________________________________ ______________________
2. __________________________________________________________ ______________________
3. __________________________________________________________ ______________________
4. __________________________________________________________ ______________________
Do you have or had any of the following?
Eye problems Staring spells Head trauma
Hearing problems Seizures Asthma
Speech problems Motor/vocal tics Liver disease
Severe headaches Heart trouble Kidney problems
Other medical problem. Explain _________________________________________________________
Have you ever been hospitalized? No Yes. Explain __________________________________
______________________________________________________________________________________
List surgical operations or injuries: Date occurred Any complications?
1. ______________________________________ ____________ ______________________
2. ______________________________________ ____________ ______________________
3. ______________________________________ ____________ ______________________
Do you have or had any difficulty with drugs/alcohol? No Yes. Any DUI? No Yes
Explain ________________________________________________________________________________
How much alcohol do you drink on average per week? __________________________________________
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Is any of your friends/relatives concern about your using drugs/alcohol? No Yes. Why? ___________
______________________________________________________________________________________
How much caffeine do you consume on average per day? _______________________________________
How many cigarettes do you smoke per day? _________________ How many years? ________________
Only for females:
Age at first menstrual period _______________ Date of last menstrual period ________________________
Are you on birth control? Yes No. Are the menstrual periods regular? Yes No
Explain _______________________________________________________________________________
List of pregnancies and age _______________________________________________________________
List of miscarriages / abortions and age ______________________________________________________
Any problems with pregnancies or deliveries? No Yes. Explain ___________________________
YOUR EDUCATION AND JOB
Current occupation ____________________________________________ Length _________________
Educational degree ____________________________________ Year completed __________________
Describe your school performance:
Grade level Academics Conduct
1. Elementary School
2. Middle School
3. High School
4. College
Did you pass each grade/year? Yes No. Explain ________________________________________
Were you ever enrolled in special services for Reading problems
Mathematics problems Emotional/Behavioral problems
Speech and language disorder None
Occupational and military history:
Employer Type of job / position Years of service
1.
2.
3.
Have you ever been suspended or fired from work? No Yes. Explain ____________________
______________________________________________________________________________________
Psychiatry Associates, PC: Patient Questionnaire - Rev Feb, 2011. Page 6 of 6
