Psychiatry Associates, P.C.

1736 Oxmoor Road. Suite 103

Birmingham, AL 35209
Telephone: 879 2120. Telecopier: 879 2125

PATIENT QUESTIONNAIRE
______________________________________________________________________________________

Full name ______________________________________________________ Date: ________________

Male; Female Birthdate __________ Marital status __________ Age ________ Race ________

Address __________________________________________________Home phone _________________

Occupation _______________________________________________ Mobile phone __________________

Other significant contact_________________________________________ Phone __________________

Referred by _______________________________________________Relation ______________________

YOUR CURRENT CLINICAL PROBLEMS

List problems for which evaluation is sought: Length of time

1. ______________________________________________________________ _______________
2. ______________________________________________________________ _______________
3. ______________________________________________________________ _______________
4. ______________________________________________________________ _______________
5. ______________________________________________________________ _______________
6. ______________________________________________________________ _______________

Impairment associated with current problems:

Not at all A little bit Moderately Quite a bit Extremely
1. Work / School
2. Social life
3. Daily activities

What have you tried so far to correct these problems (changes in life, psychotherapy, drugs)?

______________________________________________________________________________________

______________________________________________________________________________________

What specific event(s) caused you to seek help at this time? ______________________________________

______________________________________________________________________________________
List all clinicians that have evaluated or treated you: None
Clinician Reason Type of treatment Year and length
1.
2.
3.
4.

List prescribed and non-prescribed medications you are presently taking: None
Medication Reason Dosage Length of treatment
1.
2.
3.
4.
5.

YOUR PRESENT LIFE

Partner’s or spouse’s name ________________________________________ Years together ________

Age _________ Education _________________________ Occupation ___________________________

General relationship with partner or spouse ___________________________________________________

Physical or emotional problems _____________________________________________________________

List all persons living in the household with you:

Name Age Relationship Education Occupation

1.
2.
3.
4.
5.

Please check all events that may have occurred within the past 12 months:
Significant marital conflicts Marriage
Separation Pregnancy
Divorce Birth of child
Spouse with emotional difficulties Gain of new family member
Death of spouse Child leaving home

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 Death of close family member Significant conflicts at work
Death of close friend Losing job
Personal injury or illness Change in job
Change in financial status Legal problems
Change in residence Other stress __________________________

Leisure and recreational activities ___________________________________________________________

Religious affiliation and practice ____________________________________________________________

Do you have any legal problems? No Yes. Explain _________________________________________

YOUR FAMILY

Mother’s full name _____________________________________________________________________

Age _________ Education ________________________ Occupation ____________________________

General relationship with mother ___________________________________________________________

Health problems or cause of death __________________________________________________________

Father’s full name ______________________________________________________________________

Age _________ Education ________________________ Occupation ____________________________

General relationship with father ____________________________________________________________

Health problems or cause of death __________________________________________________________

Brothers and sisters:

Name Age Education Occupation Relationship
1.
2.
3.
4.

Check if any natural parent, brother, sister, uncle, aunt, cousin or grandparent has:
Attention deficit/hyperactivity disorder Problems with anxiety or panic attacks
Learning disabilities Addictions (alcohol, drugs, gambling, sex)
Mental retardation Schizophrenia
“Blues”, depressions Other psychiatric problem
Attempted suicide Tics, seizures or neurological problems
Bipolar/Manic depressive illness Legal problems

Please describe and indicate relation ________________________________________________________

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______________________________________________________________________________________

______________________________________________________________________________________

YOUR LIFE STORY

Were there any problems with your mother’s pregnancy or delivery of you? No Yes

Explain _______________________________________________________________________________

Were you born full term? Yes No. Mother’s age when you were born _____________

Did you experience any separations from your parents as a child? No Yes. Explain _______

______________________________________________________________________________________

What were you like as a child?

Affectionate Very sensitive Irritable Moody
Content Distractible Overly active Aggressive
Fearful Playful Fussy / cranky Shy
Physically sick Quiet Nervous Obedient

Have you ever experienced verbal / physical abuse? No Yes. Explain ____________________

______________________________________________________________________________________

Have you ever experienced sexual abuse? No Yes. Explain ___________________________

______________________________________________________________________________________

What were you like during adolescence?

Confident Shy Overly active Happy
Sociable Aggressive Forgetful Defiant
Irritable Peaceful Explosive Responsible
Rebellious Depressed Unconventional Moody

List some good things about you. What can you do well? Special talents? ___________________________

______________________________________________________________________________________

How old were you when you first had sex? _________ How many sexual partners have you had? ________

Any sexual issues ? No Yes. Explain ______________________________________________

______________________________________________________________________________________

Have you been married more than once? No Yes. Explain ___________________________

______________________________________________________________________________________

______________________________________________________________________________________

Psychiatry Associates, PC: Patient Questionnaire - Rev Feb, 2011. Page 4 of 6

List all children residing away from home or deceased:
Name Age Education Occupation Relationship
1.
2.
3.
4.

YOUR PHYSICAL HEALTH AND HABITS

Your physician or family doctor ________________________________ ___ Phone ___________________

Are you allergic to medication or anything? No Yes. Explain _____________________

______________________________________________________________________________________

List all physical problems presently under treatment or observation: Length of time

1. __________________________________________________________ ______________________

2. __________________________________________________________ ______________________

3. __________________________________________________________ ______________________

4. __________________________________________________________ ______________________

Do you have or had any of the following?

Eye problems Staring spells Head trauma
Hearing problems Seizures Asthma
Speech problems Motor/vocal tics Liver disease
Severe headaches Heart trouble Kidney problems
Other medical problem. Explain _________________________________________________________

Have you ever been hospitalized? No Yes. Explain __________________________________

______________________________________________________________________________________

List surgical operations or injuries: Date occurred Any complications?

1. ______________________________________ ____________ ______________________

2. ______________________________________ ____________ ______________________

3. ______________________________________ ____________ ______________________

Do you have or had any difficulty with drugs/alcohol? No Yes. Any DUI? No Yes

Explain ________________________________________________________________________________

How much alcohol do you drink on average per week? __________________________________________

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Is any of your friends/relatives concern about your using drugs/alcohol? No Yes. Why? ___________

______________________________________________________________________________________

How much caffeine do you consume on average per day? _______________________________________

How many cigarettes do you smoke per day? _________________ How many years? ________________

Only for females:

Age at first menstrual period _______________ Date of last menstrual period ________________________

Are you on birth control? Yes No. Are the menstrual periods regular? Yes No

Explain _______________________________________________________________________________

List of pregnancies and age _______________________________________________________________

List of miscarriages / abortions and age ______________________________________________________

Any problems with pregnancies or deliveries? No Yes. Explain ___________________________

YOUR EDUCATION AND JOB

Current occupation ____________________________________________ Length _________________

Educational degree ____________________________________ Year completed __________________

Describe your school performance:
Grade level Academics Conduct
1. Elementary School
2. Middle School
3. High School
4. College

Did you pass each grade/year? Yes No. Explain ________________________________________

Were you ever enrolled in special services for Reading problems

Mathematics problems Emotional/Behavioral problems
Speech and language disorder None

Occupational and military history:

Employer Type of job / position Years of service

1.
2.
3.

Have you ever been suspended or fired from work? No Yes. Explain ____________________
______________________________________________________________________________________

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