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.

Do you give us permission to coordinate care with this person/facility?
Do you give us permission to coordinate care with this person/facility?
Current Symptoms Checklist:

Exercise Level:

Do you exercise regularly?
General Stress Level:

Risk Assessment:

Have you ever had feelings or thoughts that you didn’t want to live?
If you answered no, skip to “Past Psychiatric History” section. If yes, continue. Do you currently feel that you don’t want to live?

Past Psychiatric History:

Have you ever had an EKG?
If yes, the EKG was:

Women Only:

Are you currently pregnant or do you think you might be pregnant?
Are you planning to get pregnant in the near future?
Have you had surgical sterilization (tubal ligation)?

Treatment History:

Have you ever received outpatient treatment?
Psychiatric Hospitalization:

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)


Mood Stabilizers:

Antipsychotics/Mood Stabilizers:


ADHD Medications:

Antianxiety Medications:

Has any family members been treated with a psychiatric medication?

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.**

Caffeine Intake:

Tobacco History:

Have you ever smoked cigarettes/cigars?
In the past?
Do you use chewing tobacco?

Educational History:

Did you attend college?

Trauma History:

Do you have a history of being abused emotionally, sexually, physically, or by neglect?

Alcohol/Substance (Drug) Use:

Have you ever been treated for alcohol or drug use or abuse?
Have you ever felt that you should reduce the number of alcoholic drinks or substances you consume?
Have people annoyed you by criticizing your drinking or substance use?
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?
Do you think that you may have a problem with alcohol or substances?
Have you used any “street drugs” in the past 3 months?
Have you ever over-used prescription medication?

Check if you have ever tried the following:

Have you ever tried Methamphetamine?
Have you ever tried Cocaine?
Have you ever tried Stimulants (pills)?
Have you ever tried Heroin?
Have you ever tried LSD or Hallucinogens?
Have you ever tried Marijuana?
Have you ever tried Pain Killers (not prescribed)?
Have you ever tried Methadone?
Have you ever tried Alcohol?
Have you ever tried Ecstasy?
Have you ever tried Steroids?
Have you ever tried Tranquilizer/sleeping pills?
Have you ever tried Other?


Are you currently:

Family Life:

Do you have children?

Legal History:

Have you ever been arrested?
Do you have any pending legal problems?

Spiritual Life:

Do you belong to a religion or spiritual group?
Do you find your involvement helpful during this illness, or does the involvement make things more difficult or stressful for you?

Miscellaneous Medical Information:

Are you legally blind?
Are you deaf?
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