Google Forms: Sign-in

WELCOME TO ALIGN - Patient History Form

Thank you for your interest to join the ALIGN Family. We are eager to assist you in aligning your mental health goals with your reality while meeting you where you are through Telehealth. Please complete our history form at least 24 hours prior to your scheduled appointment. If this has not been received, your appointment may be rescheduled.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date

Medical History
Who is your Primary Care Provider? (N/A if you do not have one)
When was the last time you had a wellness exam? (N/A if you have not had one within the last year or if unknown)
Please list any medical conditions, diseases, and surgeries that you have or have had. (I.E. asthma, diabetes, hepatitis C, herpes, hysterectomy)
Please list any allergies to food and/or drugs.
How tall are you?
How much do you currently weigh?
Has there been any reason weight loss or weight gain? Which one? (N/A if Not Applicable)

	Yes	No
ADHD
Autism/Aspergers
Bipolar Disorder (Manic-Depressive) Disorder)
Borderline Personality Disorder
Conduct Disorder
Generalized Anxiety Disorder
Insomnia
Major Depressive Disorder
Obsessive Compulsive Disorder
Oppositional Defiant Disorder
Panic Disorder
Psychosis
PTSD
Schizoaffective Disorder
Schizophrenia

	Yes	No
Domestic Violence
Emotional Abuse
Neglect
Physical Abuse
Sexual Abuse
Traumatic Incident in your Life
Traumatic Loss of Individuals
Verbal Abuse

	Not at all	Several days	More than half the days	Nearly every day
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself — or that you are a failure or have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching television
Moving or speaking so slowly that other people could have noticed? Or so fidgety or restless that you have been moving a lot more than usual
Thoughts that you would be better off dead, or thoughts of hurting yourself in some way

	Not at all	Several days	More than half the days	Nearly every day
Feeling nervous, anxious, or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless that it's hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might happen

WELCOME TO ALIGN - Patient History Form

	Yes	No
...you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?
...you were so irritable that you shouted at people or started fights or arguments?
...you felt much more self-confident than usual?3
...you got much less sleep than usual and found you didn’t really miss it?
...you were much more talkative or spoke much faster than usual?
...thoughts raced through your head or you couldn’t slow your mind down?
...you were so easily distracted by things around you that you had trouble concentrating or staying on track?
...you had much more energy than usual?
...you were much more active or did many more things than usual?
...you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?
...you were much more interested in sex than usual?
...you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?
...spending money got you or your family into trouble?
If you checked YES to more than one of the above, have several of these ever happened during the same period of time?

	Yes	No
Have any of your blood relatives (i.e. children, siblings, parents, grandparents, aunts, uncles) had manic-depressive illness or bipolar disorder?
Has a health professional ever told you that you have manic-depressive illness or bipolar disorder?