Behavioral Health Questionnaire Behavioral Health Questionnaire Behavioral Health Questionnaire This is not the Waterfall Registration. Patients completing this Behavioral Health Questionnaire will still need to complete the Waterfall Registration. Name * Name First First Last Last Phone Number * Date Of Birth * Primary Care Physician: Do you give us permission to coordinate care with this person/facility? * Yes No Current Therapist/Counselor: Do you give us permission to coordinate care with this person/facility? * Yes No Pharmacy: What are the problem(s) for which you are seeking help? * What are your treatment goals? * Current Symptoms Checklist: * Depressed Mood Crying Spells Anxiety Attacks Unable To Enjoy Activities Racing Thoughts Avoidance Sleep Pattern Disturbance Impulsivity Hallucinations Loss Of Interest Increase Risky Behavior Suspiciousness Concentration/Forgetfulness Increased Libido Excessive Worry Change In Appetite Excessive Energy Decreased Libido Excessive Guilt Increased Irritability Fatigue Excessive Worry Exercise Level: Do you exercise regularly? * Yes No How many days a week do you get exercise? * How much time each day do you exercise? What kind of exercise do you do? General Stress Level: * Low Moderate High Risk Assessment: Have you ever had feelings or thoughts that you didn’t want to live? Yes No If you answered no, skip to “Past Psychiatric History” section. If yes, continue. Do you currently feel that you don’t want to live? Yes No How often do you have these thoughts? When was the last time you had thoughts of dying? Have you ever tried to kill or harm yourself before? On a scale of 1 to 10, (ten being strongest) how strong is your desire to kill yourself currently? Has anything happened recently to make you feel this way? Would anything make it better? Have you planned a time for this? Is the method you would use readily available? Do you have access to weapons? Is there anything that would stop you from killing yourself? Past Psychiatric History: Allergies Current Weight: * Height: * List ALL current prescriptions and medications, how often you take them, estimated start date: (If none, write none) * Current over the counter medications or supplements? * Current medical problem(s)? * Past medical problem(s)? * Past surgeries? * Have you ever had an EKG? * Yes No If yes, when? If yes, the EKG was: Normal Abnormal Unknown Women Only: Date of last menstrual cycle? Birth control method? How many times have you been pregnant? How many live births? Are you currently pregnant or do you think you might be pregnant? Yes No Are you planning to get pregnant in the near future? Yes No Have you had surgical sterilization (tubal ligation)? Yes No Treatment History: Have you ever received outpatient treatment? * Yes No If yes, please describe when, by whom, and the nature of treatment? Reason: Dates Treated: By Whom: Psychiatric Hospitalization: * Yes No If yes, please describe when, where, and the nature of treatment? Reason: Dates Hospitalized: Where: Past Psychiatric Medications If you have ever taken any of the following medications, please indicate the dates, dosage, and how helpful they were (if you can’t remember all the details, just write in what you do remember) Antidepressants: Prozac (fluoxetine) Zoloft (sertraline) Luvox (fluvoxamine) Paxil (paroxetine) Celexa (citalopram) Lexapro (escitalopram) Effexor (venlafaxine) Cymbalta (duloxetine) Wellbrutrin (bupropion) Remeron (mirtazapine) Serzone (nefazodone) Anafranil (clomipramine) Pamelor (nortrptyline) Tofranil (imipramine) Elavil (amitriptyline) Other: Mood Stabilizers: Tegretol (carbamazepine) Lithium Depakote (valproate) Lamictal (lamotrigine) Topamax (topiramate) Other: Antipsychotics/Mood Stabilizers: Seroquel (quetiapine) Zyprexa (olanzepine) Geodon (ziprasidone) Abilify (aripiprazole) Clozaril (clozapine) Haldol (haloperidol) Prolixin (fluphenazine) Risperdal (risperidone) Other: Sedative/Hypnotics: Ambien (zolpidem) Sonata (zaleplon) Rozerem (ramelteon) Restoril (temazepam) Desyrel (trazodone) Other: ADHD Medications: Adderall (amphetamine) Concerta (methylphenidate) Ritalin (methylphenidate) Strattera (atomoxetine) Other: Antianxiety Medications: Xanax (alprazolam) Ativan (lorazepam) Klonopin (clonazepam) Valium (diazepam) Tranxene (clorazepate) Buspar (buspirone) Other: Has any family members been treated with a psychiatric medication? * Yes No If yes, who was treated, what medications did they take, and how effective was the treatment? (If known): Personal and Family Medical History: *Please indicate if it was YOU, or Family Member(s), as well as the Doctor/Facility that did the diagnosis)* **Please limit this to the first degree relatives.** ADD/ADHD Anxiety Disorder Abuse/Domestic Violence Anemia Asthma TexBipolar Disorder COPD Cancer Congestive Heart Failure Constipation Coronary Artery Disease Depression Diabetes Eating Disorder Fibromyalgia GI Problems Headaches Heart Disease Hepatitis High Cholesterol Hypertension Hyperthyroidism Hypothyroidism Caffeine Intake: How many caffeinated beverages do you drink a day? (List Coffee, Soda, Tea) Tobacco History: Have you ever smoked cigarettes/cigars? * Yes No Currently? * Yes No How many packs per day? How many years? In the past? * Yes No How many years? When did you quit? Do you use chewing tobacco? * Yes No How often? How many years? Educational History: Highest grade completed? * Did you attend college? * Yes No Major? What is your highest educational level or degree attained? * Trauma History: Do you have a history of being abused emotionally, sexually, physically, or by neglect? * Yes No Please describe when, where, and by whom? Alcohol/Substance (Drug) Use: Have you ever been treated for alcohol or drug use or abuse? * Yes No If yes, for which substance? Please describe when, where and by whom you received treatment? How many days per week do you drink alcohol? How many days per week do you use substances? What is the least number of drinks you will consume in a day? What is the greatest number of drinks you will consume in a day? In the past three months, what is the largest number of alcoholic drinks you have consumed in one day? Have you ever felt that you should reduce the number of alcoholic drinks or substances you consume? Yes No Have people annoyed you by criticizing your drinking or substance use? Yes No Have you ever had a drink or used substances first thing in the morning to steady your nerves or to get rid of a hangover? Yes No Do you think that you may have a problem with alcohol or substances? Yes No Have you used any “street drugs” in the past 3 months? Yes No If yes, which ones? Have you ever over-used prescription medication? Yes No If yes, which ones? Check if you have ever tried the following: Have you ever tried Methamphetamine? * Yes No If yes, how long and when did you last use? Have you ever tried Cocaine? * Yes No If yes, how long and when did you last use? Have you ever tried Stimulants (pills)? * Yes No If yes, how long and when did you last use? Have you ever tried Heroin? * Yes No If yes, how long and when did you last use? Have you ever tried LSD or Hallucinogens? * Yes No If yes, how long and when did you last use? Have you ever tried Marijuana? * Yes No If yes, how long and when did you last use? Have you ever tried Pain Killers (not prescribed)? * Yes No If yes, how long and when did you last use? Have you ever tried Methadone? * Yes No If yes, how long and when did you last use? Have you ever tried Alcohol? * Yes No If yes, how long and when did you last use? Have you ever tried Ecstasy? * Yes No If yes, how long and when did you last use? Have you ever tried Steroids? * Yes No If yes, how long and when did you last use? Have you ever tried Tranquilizer/sleeping pills? * Yes No If yes, how long and when did you last use? Have you ever tried Other? * Yes No If yes, what, and for how long and when did you last use? Employment: Are you currently: * Working Student Unemployed Disabled Retired What is/was your occupation? * Where do you work? How long in present position? Family Life: Do you have children? Yes No If yes, list ages and gender: Describe your relationship with your children List everyone who currently lives with you: Legal History: Have you ever been arrested? Yes No Do you have any pending legal problems? Yes No Spiritual Life: Do you belong to a religion or spiritual group? * Yes No If yes, what is the live of your involvement? Do you find your involvement helpful during this illness, or does the involvement make things more difficult or stressful for you? More Helpful More Stressful Miscellaneous Medical Information: Are you legally blind? Yes No Left eye only Right eye only Both eyes Are you deaf? Yes No Left ear only Right ear only Both ears Is there anything else that you would like us to know? If you are human, leave this field blank. Submit Start Over
