LAKE OSWEGO PSYCHIATRIC ASSOCIATES
Allen L. Stark, MD & Carol L.R. Stark, MD
Symptom Questionnaire
Please fill out the form below as completely as possible. There is a text box at the bottom of the form to provide extra room for any additional information.
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Occupation
*
Marital Status
*
Single
Married
Divorced
Widowed
Children
*
Highest Level of Education
*
1. What is the main problem today?
*
2. Do you have other concerns today?
*
Yes
No
If yes, what are they?
3. Have you ever seen a psychiatrist, psychologist, social worker, or counselor before?
*
Yes
No
Rather not say
4. Are you taking any medication, prescribed or over-the-counter?
*
Yes
No
If yes, please list all your current medications and supplements, both prescribed and over-the-counter.
5. Do you drink alcohol?
*
Yes
No
Rather not say
If yes, how much?
If yes, how often?
6. Do you drink caffeine?
*
Yes
No
Rather not say
If yes, how many cups of coffee per day?
If yes, how many cola drinks per day?
If yes, how many cups of tea per day?
7. Do you use tobacco?
*
Yes
No
Rather not say
If yes, what form?
If yes, how much?
8. Do you use recreational drugs?
*
Yes
No
Rather not say
If yes, what type(s)?
If yes, how often?
9. Are you having problems on the job or at school?
*
Yes
No
Rather not say
10. Are you having problems sleeping (too much, too little)?
*
Yes
No
Rather not say
11. Has your appetite increased or decreased?
*
Yes
No
Rather not say
12. Do you ever make yourself throw up?
*
Yes
No
Rather not say
13. Have you been feeling sad?
*
Yes
No
Rather not say
14. Have you had thoughts of hurting yourself?
*
Yes
No
Rather not say
15. Do you sometimes feel too happy or excited?
*
Yes
No
Rather not say
16. Do you sometimes feel you can't control your thoughts or actions?
*
Yes
No
Rather not say
17. Are you worried about losing your temper?
*
Yes
No
Rather not say
18. Are you afraid you might hurt someone?
*
Yes
No
Rather not say
19. Are there times for which you have no memory?
*
Yes
No
Rather not say
20. Have you ever had any unusual experiences?
*
Yes
No
Rather not say
If yes, please explain:
21. Are you having trouble with your memory?
*
Yes
No
Rather not say
22. Do you have trouble concentrating?
*
Yes
No
Rather not say
23. Is reading difficult for you?
*
Yes
No
Rather not say
24. Do you wish you had either more or less interest in sex?
*
Yes
No
Rather not say
25. Do you ever feel there is more than one person inside of you?
*
Yes
No
Rather not say
26. Have you ever been physically or verbally abused?
*
Yes
No
Rather not say
27. Have you ever been sexually abused?
*
Yes
No
Rather not say
28. Are you worried about the behavior of someone close to you?
*
Yes
No
Rather not say
29. Are you having problems with your spouse, significant other, or partner?
*
Yes
No
Rather not say
30. Are you having problems with a child?
*
Yes
No
Rather not say
31. Are you having problems with a parent or in-law?
*
Yes
No
Rather not say
32. Are you having any major physical problems?
*
Yes
No
Rather not say
If yes, please indicate where:
Allergies
Cancer
Handicaps
Hearing
Heart
Intestines
Joints
Kidneys
Lungs
Reproductive Organs
Stomach
Vision
Other
33. Have you ever been in the hospital?
*
Yes
No
Rather not say
If yes, when?
If yes, what was the problem?
34. Are you on a special diet?
*
Yes
No
Rather not say
35. Have you consulted a chiropractor, naturopath, or nutritionist?
*
Yes
No
Rather not say
36. Do you exercise regularly?
*
Yes
No
Rather not say
If yes, what form(s)?
If yes, how often?
36. Do you have a religious or spiritual affiliation?
*
Yes
No
Rather not say
If yes, what is it?
If yes, are you currently active in this affiliation?
Yes
No
38. Are you a member of a service or social organization?
*
Yes
No
Rather not say
If yes, what is it?
39. If you need extra room to clarify any of your answers, please do so here:
40. Is there anything else I should know about you?
By signing, you certify that the above information is true to the best of your knowledge.
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
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