New Patient Demographics and History

1
Patient NamePlease fill in the name on your insurance card
First Name
Last Name
2
Patient’s sex
Male
Female
Other
3
Patient’s Date of Birth
Date
Month
Day
Year
4
Patient’s Social Security Number
5
Patient’s Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
Primary Contact number for patient
Area Code
Phone Number
7
Is it okay to leave a message at this number?
YESNO
8
Patient Work Number
Area Code
Phone Number
9
Patient’s Email
example@example.com
10
Employment Status of Patient
Full Time
Part Time
Not Working
Disabled
Retired
Student
Other
11
Name of Employer
12
Marital Status of Patient
Single
Married
Divorced
Widowed
Other
13
Language(s) spoken by patient
English
Spanish
Other
14
What category best describes your race (one or more may be marked)
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
I choose not to answer
Other
15
Please specify your ethnicity
Hispanic or Latino
Not Hispanic or Latino
16
Nationality of Patient
U.S. citizen
Other
17
Emergency Contact for patient
First Name
Last Name
18
Emergency Contact Phone Number
Area Code
Phone Number
19
Emergency Contact Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
20
How is the emergency contact related to patient?
21
Other Contact Name
First Name
Last Name
22
Other Contact Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
23
Other Contact Phone Number
Area Code
Phone Number
24
How is other contact related to the patient?
25
What pharmacy do you use locally?
26
Local Pharmacy Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
27
Local Pharmacy Phone Number
Area Code
Phone Number
28
What is your mail order pharmacy?
29
Insurance Company Name (primary)
30
Subscriber’s Insurance ID number
31
Group Number
32
Primary Insurance Effective Date
Date
Month
Day
Year
33
Primary Insurance Subscriber’s Name
34
Primary Insurance Subscriber’s Date of Birth
Date
Month
Day
Year
35
Primary Insurance Subscriber’s Sex
Female
Male
36
Patient’s relationship to subscriber of Primary Insurance
Spouse
Child
Other
37
Does the patient have secondary insurance?
YESNO
38
Secondary Insurance Carrier
39
Secondary Insurance Subscriber ID number
40
Secondary Insurance Subscriber’s Name
41
Secondary Insurance Subscriber’s Date of Birth
Date
Month
Day
Year
42
Secondary Insurance Subscriber’s Sex
Female
Male
43
Patient’s relationship to subscriber of Secondary Insurance
Spouse
Child
Other
44
Any other information you feel we need to know?
45
Have you ever been treated any of the following medical conditions?
Acid Reflux (GERD)
Arthritis
Asthma
Bleeding Disorders
Cancer
Chronic pain
COPD/Emphysema
Dementia or memory loss
Diabetes mellitus
Head trauma/loss of consciousness
Heart disease/heart attack
Hepatitis B
Hepatitis C
High blood pressure
High choleterol
High thyroid function
HIV disease
Iron deficiency/anemia
Irritable Bowel Syndrome
Kidney disease
Low thyroid function
Migraines or chronic headaches
Parkinson's disease
Pituitary tumor
Seizures/epilepsy
Sleep apnea
Stroke or TIA (min-stroke)
Vitamin B12 deficiency
Vitamin D deficiency
None
Other
46
Please list any other medical conditions not listed above
47
Have you ever had an allergy or bad reaction to a medication?
YESNO
48
Medication Allergies/Adverse ReactionsPlease list any allergies or severe past reactions to medications
49
Have you ever had a surgery or medical procedure?
YESNO
50
Surgical HistoryPlease list prior surgeries or medical procedures
51
Are you currently taking any medications or supplements?
YESNO
52
Current MedicationsPlease list any medications and/or supplements that you are currently taking
53
Primary Care Provider Name
First Name
Last Name
Suffix
54
Primary Care Provider Phone Number
Area Code
Phone Number
55
Your other healthcare providersPlease list their name, practice name and contact information (if known)
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Ok
56
Have you had previous treatment for a mental health concern?* This field is required.
YESNO
57
Previous mental health provider Please include name, practice name and city, if known
58
Are you currently seeing a psychotherapist or counselor?* This field is required.
YESNO
59
Therapist/Counselor Name
First Name
Last Name
60
Therapist/Counselor Phone Number
Area Code
Phone Number
61
Have you ever been hospitalized or participated in a rehab or outpatient program, like an IOP or PHP?
YESNO
62
Psychiatric Hospitalizations/Rehab/IOP or PHPPlease list below any inpatient, residential or intensive outpatient psychiatric treatment that you have received.
63
Please list any information on past suicide attempts
64
Please list information on any history of self harm or mutilation
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Ok
65
There is another form available to list past medication trials. If you have tried medications or non-medication interventions like ECT, TMS, etc, please complete that form.
66
Please provide any additional information you think your provider should know about your psychiatric history. Thank you.
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Ok
67
Parents' History
68
Do you have any siblings?
YESNO
69
Siblings' History
70
Do you have any biological children?
YESNO
71
Children's History
72
Other relatives with relevant psychiatric historyPlease provide relationship and known history
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Ok
Ok
73
Was your pregnancy and delivery normal, to the best of your knowledge?Did your mother have any complications or difficulties during your pregnancy?
YESNO
74
Please list any complications with your pregnancy/birth/delivery
75
Did you experience any developmental delays growing up (walking, talking, school delay, etc)?
YESNO
76
Please list any developmental delays and treatments for them that you underwent as a child (OT, PT, speech therapy, etc)
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Ok
77
Did you have any learning issues as a child?Difficulties in school, specific subjects, speech, etc
YESNO
78
Please list any learning issues and treatments received as a child (include speech therapy, OT, IEP/540, etc)
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Ok
Ok
79
Did you have any issues making friends or connecting to people when you were young?
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Ok
80
Where were you born and raised?
81
With whom did you grow up
Both parents
Mother
Father
Other relative
Adopted
Other
82
Highest level of eduation
Non-HS graduate
GED
High School
2 year degree
4 year degree
Graduate degree
Post graduate
Vocational training
83
Marital Status
Single, never married
Divorced and single
Divorced and remarried
Widowed and single
Widowed and remarried
Separated
Partnered
Married
Other
84
Partner's name
85
Years together
86
With whom do you live?
87
Employment
Full Time
Part time
Stay at home
Retired
Unemployed/not working
Furloughed
Short term disability
Long term disability
Student
Self employed
Other
88
Occupation
89
Employer
90
Did/do you serve in the military?
YESNO
91
What branch(es)?
Air Force
Army
Coast Guard
Marines
National Guard
Navy
Other
92
How long did you serve?
93
Were you honorably discharged?
YESNO
94
Legal History
None
Arrest
DUI
Jail/Prison time
Currently on probation
Other
95
Please list hobbies and interests/community organizations that you enjoy.
96
Regular Exercise
None
Cardio
Weight training
Other
97
Pets at home
98
Have you ever been the victim of violence?
Emotional
Domestic violence
Physical
Sexual
Witnessed abuse/violence
None
Other
99
Are you currently safe?
YESNO
100
How many servings of caffeine do you consume in an average day?
1-2
0
1-2
3-4
5-6
>6
101
Recreational Drug useIndicate past or current use, non-medicinally
Past Use
Current Use
Rehab
Canabis/THC
Row 0, Column 0
Row 0, Column 1
None
1-2 Times
>3 times
Row 0, Column 2
Cocaine/crack
Row 1, Column 0
Row 1, Column 1
None
1-2 Times
>3 times
Row 1, Column 2
Meth
Row 2, Column 0
Row 2, Column 1
None
1-2 Times
>3 times
Row 2, Column 2
Stimulants
Row 3, Column 0
Row 3, Column 1
None
1-2 Times
>3 times
Row 3, Column 2
Ketamine
Row 4, Column 0
Row 4, Column 1
None
1-2 Times
>3 times
Row 4, Column 2
MDMA (Ecstasy)
Row 5, Column 0
Row 5, Column 1
None
1-2 Times
>3 times
Row 5, Column 2
Psilocybin (shrooms)
Row 6, Column 0
Row 6, Column 1
None
1-2 Times
>3 times
Row 6, Column 2
LSD
Row 7, Column 0
Row 7, Column 1
None
1-2 Times
>3 times
Row 7, Column 2
Huffing
Row 8, Column 0
Row 8, Column 1
None
1-2 Times
>3 times
Row 8, Column 2
Pain pills/Heroin
Row 9, Column 0
Row 9, Column 1
None
1-2 Times
>3 times
Row 9, Column 2
Canabis/THC
Cocaine/crack
Meth
Stimulants
Ketamine
MDMA (Ecstasy)
Psilocybin (shrooms)
LSD
Huffing
Pain pills/Heroin
Past Use
Row 0, Column 0
Current Use
Row 0, Column 1
Rehab
None
1-2 Times
>3 times
Row 0, Column 2
Past Use
Row 1, Column 0
Current Use
Row 1, Column 1
Rehab
None
1-2 Times
>3 times
Row 1, Column 2
Past Use
Row 2, Column 0
Current Use
Row 2, Column 1
Rehab
None
1-2 Times
>3 times
Row 2, Column 2
Past Use
Row 3, Column 0
Current Use
Row 3, Column 1
Rehab
None
1-2 Times
>3 times
Row 3, Column 2
Past Use
Row 4, Column 0
Current Use
Row 4, Column 1
Rehab
None
1-2 Times
>3 times
Row 4, Column 2
Past Use
Row 5, Column 0
Current Use
Row 5, Column 1
Rehab
None
1-2 Times
>3 times
Row 5, Column 2
Past Use
Row 6, Column 0
Current Use
Row 6, Column 1
Rehab
None
1-2 Times
>3 times
Row 6, Column 2
Past Use
Row 7, Column 0
Current Use
Row 7, Column 1
Rehab
None
1-2 Times
>3 times
Row 7, Column 2
Past Use
Row 8, Column 0
Current Use
Row 8, Column 1
Rehab
None
1-2 Times
>3 times
Row 8, Column 2
Past Use
Row 9, Column 0
Current Use
Row 9, Column 1
Rehab
None
1-2 Times
>3 times
Row 9, Column 2
1 of 10
102
Alcohol UseHow often do you consume alcohol?
Never
Never
A few times a year
A few times a month
A few times a week
Daily
103
Alcohol QuantityHow much alcohol do you consume when you drink, on average?
1-2 servings
1-2 servings
3-4 servings
5-6 servings
7-8 servings
9-10 servings
>10 servings
104
Have you ever experienced any of the following due to alcohol use?
Blackouts
Withdrawal seizure
Other severe withdrawal symptoms (high BP, high HR, agitation, confusion)
Delirium tremendous (DTs)-requires hospitalization
Mild withdrawal symptoms (nausea, shakes, sweating)
Memory loss
Needing an “eye opener”-drinking upon wakening
Craving alcohol when not drinking
105
Have you required the following treatment due to alcohol use?
Medical hospitalization for detox
Non-ICU Detoxification
>90 day residential treatment
30-60 day residential treatment
Long term sober living
Intensive outpatient rehab program
Alcoholic Anonymous or other recovery program
106
Do you feel that you have a problem with alcohol?
YESNO
107
Any other information regarding substance use that you feel your provider needs to know?
Huge
Large
Normal
Small
Ok
Ok
108
Is there anything else you feel your provider needs to know? Any specific issues you hope to address at your first appointment?
Huge
Large
Normal
Small
Ok
Ok
Should be Empty: