To be completed by Patient
Client Questionnaire
Client(s) Name: ______SSN#: ______- ______- ______
Name of Person Completing Form: ______Relationship to Patient: ______
(if other than client)
Marital Status of Client Race/Ethnic Origin of Client (Optional) Sex of Client Custody
Never Married Divorced White American Indian Male (if client is dependent)
Married Separated African American Asian Female Mother:
Cohabitating Widowed Hispanic Bi-Racial Father:
Other Joint:
Other:
Present Living Arrangement: Alone Family Friends Foster Care
Guardian Other (please describe: ______
Employment Status: Full-time (35 or more hrs/week) Retired
Part-time (less than 35 hr/week) Homemaker
Employed, not working due to extended illness Full-time student
Unemployed Seasonal worker
Other (please describe): ______
Occupation: ______
Education: High School/G.E.D. Yes No Special Training: ______
Last Grade completed: ______Highest Degree: ______
Currently attending school/grade: ______
Briefly explain why you are seeking help at this time: ______
SYMPTOMS
Are you currently suicidal? Are you currently engaged in aggressive/violent behavior?
Suicidal thoughts only? Do you have aggressive/violent thoughts?
Previous suicide attempt at any time? Have you had aggressive/violent behavior or thoughts?
Please check off any of the following that apply:
Depressed mood Fear of dying or going crazy
Daily irritability Excessive fear of persons, places, animals,
Recurrent and persistent, objects, situations
thoughts/behaviors Difficulty controlling anger/bad temper in
Lack of interest or pleasure activities
Increase in appetite Loss of appetite
Increased need to sleep Decreased need for sleep
Physical abuse Psychological abuse
Recurrent distressing dreams Sexual abuse
Restlessness or inability Distressing memories that recur or intrude
to concentrate Difficulty making decisions
Fatigue or loss of energy Delusions (unreasonable thoughts or beliefs)
Do you hear or see things that others don’t?
Feelings or worthlessness or guilt Not able to control impulse to steal?
Feeling of hopelessness Preoccupation with/or frequent gambling?
Recurrent thoughts of death Distractibility
Racing thoughts or ideas Sense of reliving traumatic events
Rapid mood swings Intense reactions to certain events or anniversaries
Shortness of breath/dizziness
Periods of time which you cannot remember Detachment from feelings, people and places
Avoidance of thoughts or feelings of trauma Sweating/feeling flushed
Accelerated heart rate or chest pains Bingeing/compulsive overeating
Intentional vomiting
Diuretics or laxative misuse
Trembling or shaking Excessive dieting
Choking Physical pain
Nausea or abdominal stress Other
Feeling unreal
Numbness or tingling sensations
Compulsive exercising
Self injury
HEALTH QUESTIONNAIRE
A. What medical problems or concerns, if any, are you currently having? ______
______
Are those problems being treated? Yes No By Whom? ______
B. Are you experiencing any physical pain, either constantly or occasionally? Yes No
How much does the pain interrupt your daily living/working? 1 2 3 4
Not At All Severely
Are these problems being treated? Yes No By Whom? ______
C. Last medical examination (date): ______Primary care doctor: ______
Phone Number: ______
What prescription or non-prescription drugs are you currently taking or have taken in the last six months?
1. ______4. ______
2. ______5. ______
3. ______6. ______
ALLERGIES: Drug, food, other (list) Type of reaction:
______
______
______
List past hospitalizations (including psychiatric), operations, or serious illnesses:
Type of Illnesses/Operations Year Hospital or Doctor
1. ______
2. ______
3. ______
Are you currently pregnant? Yes No N/A
Is your menstrual period regular? Yes No N/A
What was the date of your last menstrual period? ______
Check any of the following that apply:
Tuberculosis Liver Disease Heart Disease
Chronic Bronchitis Ulcer (Stomach) or Duodenus Stroke
Emphysema Sexually Transmitted Disease Jaundice
Rheumatic Fever Kidney Disorder Hepatitis
Thyroid Disorder High Blood Pressure Asthma
Diabetes Pancreatitis Anemia
Cancer
Epilepsy (Convulsions) Other: ______
______
Family History of serious illnesses, familial disease, including mental disorders and substance abuse: ______
______
NUTRITION SCREEN
Please give as much detail as you can for either yourself or other as you complete this nutrition screen.
1. Has there been any recent change in your appetite? Yes No
Excellent Good Fair Poor
2. What is your Height ______Current Weight ______Usual Weight ______
3. Have you gained or lost weight in the past year? Yes No
If so, how much? Gained ______pounds OR Lost ______pounds
4. Do you omit any foods because of health reasons? Yes No
If yes, what are they? ______
5. Do you omit any foods because of religious reasons? Yes No
If yes, what are they? ______
6. Do you include any foods because of health benefits? Yes No
If yes, what are they? ______
7. Do you have any difficulty with: Swallowing Chewing Diarrhea Constipation
Vomiting Indigestion Heartburn
8. Do you use any purging methods? Laxatives Diuretics Diet Pills Vomiting
9. What type of exercise do you do? ______
10. Do you take vitamins or supplements? Yes No
11. Do you have any food allergies? Yes No
12. How often do you eat meals with family/significant others? ______
13. How often do you eat out? ______Which meals do you eat out most often? ______
CHEMICAL USE HISTORY
1. Do you believe you have a substance abuse problem? Yes No Yes No
2. Does someone else in your life believe you have an alcohol or substance abuse problem? Yes No Yes No
If you answered “yes” to any of the above, please describe: ______
______
Alcohol frequency/amount? ______
______
Drug use frequency/amount? ______
______
Daily tobacco usage: ______Caffeine daily usage: ______
Client’s Signature: ______Date: ______
Provider’s Signature: ______Date: ______