General Adult Pre-Evaluation Form
320 Rolling Ridge Dr., Suite 100 State College, PA 16801 814.867.0670 | (fax) 814.867.7616 www.forabrighterfuture.com General Adult Pre-Evaluation Form For a Brighter Future This questionnaire will take TIME to complete. It is designed to help your provider better understand you and will be used as an aid in developing a treatment plan that suits your needs. This information in this form will be in your Mental Health Record but the information is CONFIDENTIAL and will not be released without your written permission. Please complete ALL information in this packet. PLEASE PRINT LEGIBLY. Today’s Date: _______________________________________ NAME: _____________________________________________ DOB: _______________ AGE: _________ GENDER: M / F REASON FOR APPOINTMENT I self-referred for medication consultation I was referred for this medication consultation. Who referred you? _________________________________________________ PRIMARY CONCERN 1. Briefly list or describe the reasons or concerns that brought you to the clinic today: (check all that apply) Mood Problems Thoughts of Self Harm Problems with Eating Behaviors Anxiety Problems Anger Problems Unwanted Habits Attention Problems Problems at School or Work Other (describe below) __________________________________________________________________________________________________________ 2. What led to your decision to seek help now? MOOD Please check the current duration of each CURRENT symptom identifying how long it has been a problem for you. 1-2 weeks S: Sleeping too much / not enough How many hours/night:_________ Difficulties falling asleep How long does it take? __________ Frequent waking Waking earlier than desired Feel that you do not need sleep I: Loss of interest in pleasurable activities Low motivation Increased interest in pleasurable activities G: Excessive guilt Feeling worthless E: Decreased energy Fall asleep during the day or take naps C: Difficulties with concentration/memory as a change from your usual level A: Increased appetite Decreased appetite (Circle)Weight loss or gain? Amount in pounds _________ P: Unable to sit still Moving so slowly others notice Page 1 of 10 >1 month >6months Greater than 1 year Comments 320 Rolling Ridge Dr., Suite 100 State College, PA 16801 814.867.0670 | (fax) 814.867.7616 www.forabrighterfuture.com General Adult Pre-Evaluation Form 1-2 weeks >1 month >6months For a Brighter Future Comments Greater than 1 year S: Changes in sexual interest (circle one) Increased / Decreased Felling low self-esteem Feeling sad or depressed Feeling nothing or feeling numb Irritability Anger Temper outbursts If you have temper outbursts, what happens? (circle all that apply) Verbally snappy Yelling Throwing /Hitting Objects Hitting Others How long do they last? 1-5 minutes 5-10minutes 10-30minutes 30min- 1hour Greater than 1 hour What other changes in your mood have you noticed? __________________________________________________________________________________________________ THOUGHTS AND BEHAVIORS Please check the most appropriate response for each comment listed below. Never Previously (+6 months ago) Recently Currently (in last 6 months) (in last week) Racing thoughts More than 2 days in a row with 4 hours of sleep or less each night Feeling you can do things others are note able to Voices that others do not hear Voices telling you to hurt yourself or others Seen things that others are not able to Feel that others are against you Feel that others talk about you Being more verbally aggressive than you intended with your spouse or children or others Being more physically aggressive than you intended with your spouse or children or others A physical altercation in which you caused injury Throwing or breaking things when angry Charges or an arrest for physical violence Use of a weapon in an altercation If yes to any of the above questions, please explain your experience and the context of that event(s): ____________________________________________________________________________________________________________ SAFETY Please check the most appropriate response for each comment listed below. Never Previously (+6 months ago) Thoughts about killing yourself Thinking out a plan to kill yourself Active preparation to kill yourself (e.g. writing goodbye letter, purchasing pills, obtaining a weapon) Attempting to kill yourself Page 2 of 10 Recently Currently (in last 6 months) (in last week) 320 Rolling Ridge Dr., Suite 100 State College, PA 16801 814.867.0670 | (fax) 814.867.7616 www.forabrighterfuture.com General Adult Pre-Evaluation Form Never For a Brighter Future Previously Recently Currently (+6 months ago) (in last 6 months) (in last week) Believing that others would be “better off” if you die Engaging in self-harming behaviors, such as cutting or burning yourself, without intent to die Feeling hopeless about your life and/or future If you have/had a plan to kill yourself, what is/was the plan? (Be Specific) __________________________________________________________________________________________________________ If you had prior attempts to kill yourself, when and how? ___________________________________________________________ __________________________________________________________________________________________________________ If you have engaged in prior Self-harming, please describe the behaviors. _______________________________________________ ___________________________________________________________________________________________________________ Please check the most appropriate response for each comment listed below. Never Previously (+6 months ago) Recently Currently (in last 6 months) (in last week) Thoughts about killing or harming others Thinking out a plan to kill or harm others Active preparation to kill or harm others Attempting to kill or harm others If you have/had a plan to kill/hurt others, what is/was the plan? (Be Specific) __________________________________________________________________________________________________________ Do you have intention of killing/hurting others? Yes No ANXIETY Please check the most appropriate response for each comment listed below. Never Previously (+6 months ago) Excessive worry (Indicate Specific Worries below) Restlessness Muscle tension Headaches related to stress or worry Feel keyed up, “on edge” Panic attacks (indicate frequency and triggers below) Nervous in Crowds Avoiding social events due to fear of scrutiny Overly focus on one or two things (indicate specific things below) Continually count Line things up, or require symmetry Repeatedly check things Wash your hands excessively Bathe/Groom excessively Pull at your hair Pick at your skin Patterns of stealing or shoplifting Problematic gambling Problematic pornographic use Any other problematic habits:___________________ Page 3 of 10 Recently Currently (in last 6 months) (in last week) General Adult Pre-Evaluation Form 320 Rolling Ridge Dr., Suite 100 State College, PA 16801 814.867.0670 | (fax) 814.867.7616 www.forabrighterfuture.com For a Brighter Future Further Information Describing Symptoms Listed Above: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Have you experienced or witnessed a life threatening trauma? Yes No If yes, What? _____________________________________________________________________________________________ Have you experienced physical, sexual, verbal, or emotional abuse? Yes No If yes, please describe what happened. _________________________________________________________________________ ___________________________________________________________________________________________________________ As a result of the experience(s) do you have any of the following: Flashbacks Nightmares Startle Easily Difficulty Concentrating Avoiding people / places that remind you of the events: __________________________________ Other Symptoms _________________________________________________________________________________________ MEMORY Please check the most appropriate response for each comment listed below. Have you been more forgetful? Yes No Have you had a progressive decline in memory? Yes No Have you been losing things frequently? Yes No If yes to any above, please explain. ____________________________________________________________________ IMPULSIVITY Do you have trouble waiting? Yes No Do you talk out of turn? Yes No Do you act without thinking? Yes No If yes, explain? _____________________________________________________________________________________ EATING HABITS Is weight a concern for you? Current weight: ________lbs., Height:____________ Do you exercise regularly? Type/ Frequency/ Duration: Do you ever significantly restrict your calorie intake to control weight? Do you have eating binges? If so indicate how often below, and their consistency. Do you use laxatives or diuretics for weight control? Do you vomit for weight control? If so indicate how often below. Have you ever been in treatment for an eating disorder? If so, indicate with whom and when, and types of treatments offered. Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Further Information Describing Symptoms Listed Above: __________________________________________________________________________________________________________ PAST PSYCHIATRIC HISTORY Have you ever been diagnosed with a psychiatric illness? Please check all that apply Major Depression Obsessive-Compulsive Disorder Bipolar Disorder ADHD Schizophrenia Alcohol Abuse Anxiety Disorder Substance Abuse Post-Traumatic Stress Disorder Other (list please) Eating Disorder Page 4 of 10 320 Rolling Ridge Dr., Suite 100 State College, PA 16801 814.867.0670 | (fax) 814.867.7616 www.forabrighterfuture.com General Adult Pre-Evaluation Form For a Brighter Future Past Psychiatric Medication (continue on reverse side if more space is needed) Medication Dosage Duration Diagnosis Indicate if at any time in your life you: None Saw a school counselor Saw a chaplain/spiritual leader for counseling Saw a psychologist, social worker, or other counselor Marital Counseling List any Side effects or Benefits of the Med and Reason for Stopping Saw a physician for a mental health problem Were given medication for a mental health problem Had a substance abuse evaluation or treatment Had Residential or Group Home Placement Other (list please) Please list dates, Places, and reasons for any treatment/evaluation below. Were you ever hospitalized for mental or emotional problems? Yes / No Please list dates, Places, and reasons for any treatment/evaluation below. HABITS Drugs 1. Have you ever overused any prescription or over-the-counter drug? 2. Have you ever used any illegal drugs? Substance Age of First Use Last Use Yes / No Yes / No Current amount and frequency of use 3. Do you have any legal problems associated with the substances listed above. Yes / No If yes, please describe. ______________________________________________________________________________________ Alcohol 1. Do you drink alcohol now or have you in the past? If yes, please continue. If not, go to next section 2. How many days of the month do you drink? _______________________ 3. How much do you usually drink when you do drink? # Glasses Wine ______ and / or # Beers _______ and / or # Shots of Liquor/Hard alcohol ______ 4. How many times per month do you drink to get drunk or to get away from stressors? __________ 5. Have you ever felt you should cut down on your drinking? Page 5 of 10 Yes / No Yes / No 320 Rolling Ridge Dr., Suite 100 State College, PA 16801 814.867.0670 | (fax) 814.867.7616 www.forabrighterfuture.com General Adult Pre-Evaluation Form For a Brighter Future Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No 6. Have you ever felt annoyed by others criticizing your drinking? 7. Have you ever felt bad or guilty about your drinking? 8. Have you ever had a drink first thing in the morning (eye opener) to steady your nerves or get rid of a hangover? 9. Have you had trouble with the law due to alcohol use (e.g., DUI, drinking underage, alcohol-related violence)? 10. Have you had problems in your personal relationships or at work due to alcohol use? 11. Has your alcohol use increased in the past month? 12. Have you ever driven after drinking alcohol? 13. Have you blacked out in the past from drinking alcohol? 14. Age of First Drink_________ Date of Last drink ________ If yes to any of the above, please describe: ______________________________________________________________________ __________________________________________________________________________________________________________ MEDICAL Who is your primary care provider ? __________________________________________________________________________ Please provide the address and phone number________________________________________________________________ Did you have any major illnesses, medical problems, or developmental problems as a child? If yes, please explain: Yes / No Have you been diagnosed with any of the following: Check all that apply Head Injury Heart Problems High Cholesterol Allergies, Seasonal Diabetes Chronic Pain (see below) Other: Seizure Heart Attack High Blood Pressure Anemia Headaches Hypothyroid (underactive) Pain 1. Do you experience physical pain on a regular basis? YES 2. If yes, please rate the pain you are currently feeling: 0 None 1 2 Mild Seizures Heart Failure Obesity Asthma Kidney Problems Hyperthyroid (overactive) NO 3 Loss of Consciousness Irregular Heartbeat Cancer Liver Problems Thyroid Cancer Type/Location of pain: 4 5 Moderate 3. Is your primary care provider aware of the above reported conditions/pain? 6 7 8 Severe 9 10 Extreme Yes / No / N/A Please list all surgeries. (Please use other side if more space is needed): ________________________________________________ ___________________________________________________________________________________________________________ Females Only: Date of Last Menstrual Period ________________ Are your cycles regular? Yes / No Are you Pregnant? Yes / No What Form of birth control do you currently use? _______________________________________________________________ Do you have bothersome mood symptoms prior to your period? ____________________________________________________ Other information: ________________________________________________________________________________________ Allergies Are you allergic to any medications, foods, or other substance (e.g., latex)? YES Substance: Allergic Response: Substance: Allergic Response: Substance: Allergic Response: Page 6 of 10 NO 320 Rolling Ridge Dr., Suite 100 State College, PA 16801 814.867.0670 | (fax) 814.867.7616 www.forabrighterfuture.com General Adult Pre-Evaluation Form For a Brighter Future Current Medications List any medications you are currently taking (including over-the-counters, aspirin, laxatives, birth control pills, and alternative or herbal medicines) (continue on reverse side if more space is needed) Medication Dosage When and how long? For what condition? Review of Symptoms Are you currently having or have you had problems with: (Check any physical symptoms that apply) General well-being __ Fever __ Weight loss (>10#) __ Weight gain (>10#) __ Excess fatigue __ Recurrent Nausea / vomit __ Night sweats Cardiovascular __ Chest pain __ Irregular heartbeat __ Heart murmur __ Exercise Intolerance __ Low blood pressure __ Arm and leg swelling Eyes __ Eye symptoms __ Visual Changes Gastrointestinal __ Indigestion __ Nausea / vomiting __ Jaundice __ Abdominal pain __ Change in bowel habits __ Constipation __ Diarrhea Ears, Nose, Mouth & Throat __ Hearing loss __ Pressure in ears __ Ringing in ears __ Pain in ears __ Balance disturbance __ Dizziness __ Nasal congestion __ Nosebleeds __ Sinus problems __ Difficulty swallowing __ Sore throats Respiratory __ Chronic cough __ Shortness of breath __ Snoring __ Wheezing Page 7 of 10 Hematologic/ Lymphatic __ Anemia __ Easy bleeding / bruising __ Swollen glands Genitourinary/Breast __ Painful urination __ Blood in urine __ Difficulty urinating __ Incontinence __ Irregular menstrual cycles __ Unusual breast enlargement/tenderness __ Leakage from nipple Neurological __ Disorientation __ Fainting / blacking out __ Light headedness __ Memory problems __ Concentration problems __ Speech problems __ Facial weakness/ spasms __ Muscle weakness __ Coordination problems __ Uncontrolled shaking __ Headache __ Migraine Endocrine __ Increased appetite __ Excessive thirst __ Excessive urination __ Temperature intolerance __ Excessive sweating Immunologic __ Frequent colds / infections Skin __ Dry or scaling skin __ Rashes __ Changes in skin color __ Changes in moles Musculoskeletal __ Arm or leg weakness __ Joint pain or swelling __ Back pain General Adult Pre-Evaluation Form 320 Rolling Ridge Dr., Suite 100 State College, PA 16801 814.867.0670 | (fax) 814.867.7616 www.forabrighterfuture.com For a Brighter Future Family Health History: Please check any mental health conditions that may apply to any of your family members. Mother Father Sibling Mother’s Side Dad’s Side Anxiety (such as panic, phobia, excessive worry, or OCD) Bipolar Disorder or Manic Depression Heart Disease Depression Diabetes High Cholesterol High Blood Pressure Obesity Heart Defect Sudden Death Due to Abnormal Heart Beat Suicide Attempts or Completed Suicide Attention Deficit Hyperactivity (ADHD) Alcoholism Drug Abuse or Addiction Learning Disability or Mental Retardation Legal Problems Schizophrenia Stroke SOCIAL & DEVELOPMENTAL HISTORY Relationships: 1. Are you currently in a relationship? Yes/ No How long? _______________________ (circle all that apply) Single Married Divorced Widowed Partnered Separated Total number of marriages: What year(s) were you married? ________________________________ 2. Briefly describe your current living situation (e.g., with whom you currently live) _____________ ___________________________________________________________________________________________________________ 3. Do you have children Yes / No If so,what year(s) were they born? ___________________________________________________ Childhood: 4. How many siblings do you have?__________ What number in the birth order are you? __________(e.g. I am the 2 nd of 4 children) 5. My Childhood was: Normal Abusive Dysfunctional Rough Other:___________________ 6. Where did you grow up? 7. Who raised you? 8. Describe your current relationship(s) with your parents & siblings: ______________ _________________________________________________________________________________________________________ Home Environment: 9. Do you have guns in your home? Yes / No Do you have access to weapons otherwise? Yes / No Stressors: Indicate if you experienced any of the following at any time in your life: Experienced domestic violence None Verbal abuse Witnessed domestic violence Physical abuse Rape Emotional abuse Miscarriage Sexual abuse/assault Abortion Witnessed physical abuse Crime victim Witnessed emotional abuse War Witnessed sexual abuse Poverty Page 8 of 10 Happy childhood Unhappy childhood Death of parent Death of a child Death of someone close Filed for bankruptcy Teased by peers Natural disaster General Adult Pre-Evaluation Form 320 Rolling Ridge Dr., Suite 100 State College, PA 16801 814.867.0670 | (fax) 814.867.7616 www.forabrighterfuture.com For a Brighter Future If yes, please describe. ___________________________________________________________________________________ ___________________________________________________________________________________ 10. Are you currently experiencing any physical, sexual, or emotional abuse? Yes / No If yes, please describe ______________________________________________________________________ 11. How satisfied are you with current family life? Very unsatisfied Unsatisfied Satisfied Very satisfied 12. Are you experiencing any family problems or problems at home? If yes, describe _________________________ ____________________________________________________________________________________________________________ 13. Who do you talk to about your problems/turn to for support? 14. How satisfied are you with this support? Very unsatisfied Unsatisfied Satisfied Very satisfied Education 15. What is the highest education you have completed? GED High School 16. When did you complete each? _______ __________ Some College ____________ Bachelor’s __________ Graduate Degree ______________ Please check any of the following that applied to you during your education (grade school, high school, and/or college) or currently Low grades Being involved in after school activities Skipping a grade High grades Being held back a grade(s) Few friends Truancy Being suspended or expelled Many friends Interactions with the law Requiring special education Difficulty reading or writing Educational or learning problems Fighting in school. If yes, how often: If yes, please describe.____________________________________________________________________________________ ____________________________________________________________________________________ Occupation 17. What is your work status? Circle most applicable Employed Not Employed by Choice Unemployed Short Term Disability Long Term Disability If employed, What is your current job? _____________________________________________________________________ How long have you been there? ____________________________ How satisfied are you with your current job? Very unsatisfied Unsatisfied Satisfied Very satisfied 18. Has your current problem/concern affected your work? Yes / No Have you received any disciplinary action at work? Yes / No If yes, please explain: 19. Work History How many jobs have you held in the last 5 years ? ____________ How many jobs have you EVER been fired from?_______ Past jobs, duration and reasons for leaving, etc.: 20. Have you ever served in the military? Yes / No If So, what Branch? US Army US Navy US Marine Corps US Air Force US Coast Guard National Guard Dates of Service: ___________________________________________________________________________________ Job/Role:______________________________ Highest rank: __________________________ Type of Discharge: Regular/Honorable Dishonorable Medical Psychiatric General Other Religion and Spirituality 21. Do you consider yourself religious or spiritual? Yes / No If yes, please describe. ____________________________________________________________________________________ Page 9 of 10 General Adult Pre-Evaluation Form 320 Rolling Ridge Dr., Suite 100 State College, PA 16801 814.867.0670 | (fax) 814.867.7616 www.forabrighterfuture.com For a Brighter Future Legal/Financial 22. Are you currently experiencing any legal difficulties? If yes, please explain: 23. Are you currently experiencing any financial difficulties? If yes, please explain: Personal Habits Caffeine/Tobacco 24. Do you use caffeinated products (e.g., coffee, tea, soda, tablets, energy drinks)? If yes, what kind? How much (e.g., servings per day)? Yes / No Yes / No Yes / No 25. Do you use tobacco products? Yes / No If yes, what kind? How much (e.g., # per day)? _______ For how many years? ___________________________________________________________________________________ ADDITIONAL INFORMATION OR CONCERNS: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Thank you for taking the time to complete this pre-evaluation form. Page 10 of 10
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