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BACKGROUND HISTORY QUESTIONNAIRE
BACKGROUND HISTORY QUESTIONNAIRE
INSTRUCTIONS: Please answer all questions as accurately and completely as possible. You will have a chance to discuss answers in detail with Dr. Mangassarian. Your family or friends can help if needed.  All information is secure through our HIPPA compliant database.
56Questions
BACKGROUND HISTORY QUESTIONNAIRE
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  • 2

    Questionnaire completed by [if different than patient]:
    Relationship to patient:

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  • 3
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    How would you prefer to be contacted?                    
    DOB/AGE:  * Gender: * Race:    *    
    Ethnicity:    *    Language(s) Spoken:    *    
    Handedness (hand you write with)        *    

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    Where were you born? * .
    ... ... If in other country, when did you relocate to the U.S.? .
    Where were you raised?    *  .  Who primarily raised you?    *
    How many blood-related siblings do/did you have?     *    
    Where are you in birth order (e.g., first, last, 2nd of 5)?    *    
       

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  • 17

    When was your last eye exam? *
    When was your last hearing exam? *

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  • 18
    Please check any of the following conditions in your immediate or extended blood-related family (e.g, biological parents, biological siblings/half-siblings, your biological children, biological grandparents, biological aunts, uncles, cousins). In the column labeled “Relative,” please clarify which relative(s) have been diagnosed or treated for the condition.
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  • 20
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  • 21

    What diagnosis/diagnoses (Please type N/A if not applicable)? *
    When did you receive this/these diagnosis/diagnoses (Please type N/A if not applicable)? *

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  • 22
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  • 23
    If YES, please list all incidents of psychiatric hospitalization, length of hospitalizations (e.g., 3 days, 2 months), and year/dates of hospitalization(s): 
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  • 24
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  • 29
    Please list your current medications (including psychiatric medications) and vitamins, or attach a list.
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  • 30
    Highest Grade Level Completed
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  • 32
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  • 39
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  • 40
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  • 41
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  • 42
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  • 43

    When did you retire? *
    What field/company did you retire from? *

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  • 44
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  • 45
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  • 46
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  • 47

    Did/Do you manage or supervise people?        *    
    Company/organization:    *    
    Duration worked for/with this company?    *    

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  • 48
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  • 49
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  • 51
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  • 52

    If yes, on what basis and since when? *

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  • 53
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  • 54

    Branch and years of service: *
    Title/Position:    *    
    Deployed? If yes, please provide dates and locations:    *    
    Honorable Discharge:        *    

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  • 55
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  • 56
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  • 57

    Number of times married *
    Years married to current spouse *

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  • 60
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  • 61
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  • 62

    If yes, when? *

    Alleged charge(s):    *    

    Were you Convicted?         *    
    Are you currently under any sort of court supervision (e.g., probation)?         *    
    Are you currently involved in any lawsuits or legal actions?        *       
    Have you ever been cited for Driving Under the Influence?        *    

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