Psychiatry Questionaire Consent: PREFERRED BEHAVIORAL HEALTH 141 Market Place Drive, Suite 100 • Fairview Heights, Illinois 62208 • Phone: 618-398-4226 ***ONLINE PSYCHIATRY QUESTIONAIRE*** By signing and submitting these online client registration forms, you are signing these Agreements electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on these Agreements. *PREFERRED BEHAVIORAL HEALTH 141 Market Place Drive, Suite 100 • Fairview Heights, Illinois 62208 • Phone: 618-398-4226 ONLINE PSYCHIATRY QUESTIONAIRE By signing and submitting these online client registration forms, you are signing these Agreements electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on these Agreements.Name *Current Symptoms -- Checklist: (check all that apply) *AggressionAngerAnxietyCrying/TearfulDelusionsDepressionDistractibilityDifficulty getting out of bedEmotional trauma victimGriefHallucinationsHearing voicesHopelessnessIrritabilityLonelinessLoss of interest in activitiesMemory ImpairmentMood swingsObsessions - OCDOppositional behaviorPanic attacksParanoiaPoor concentrationRacing thoughtsSelf-mutilationSexual addictionSexual trauma victimSleep problemsSocial isolationSubstance abuseSuicidal thoughtsDo you currently take any psychiatric medications? *YesNoPlease list any current psychiatric medications: *Have you taken any psychiatric medications in the past? *YesNoPlease list any past psychiatric medications that you have taken: *Do you exercise regularly? *YesNoHave you ever been hospitalized or received In-Patient psychiatric care or substance abuse care? *YesNoIf yes, please explain: *Substance Use Status: *No history of substance abuseActive abuseEarly full remissionEarly partial remissionSustained full remissionSustained partial remissionSubstances Used: (check all that apply) *AlcoholAmphetamines/SpeedBarbituratesCocaineCrack CocaineEcstasyHallucinogens (LCD)HeroineMarijuanaMethadoneMethamphetaminePainkillersNicotine / TabaccoPCPNonePersonal Medical History -- Have you ever had any of the following? (check all that apply) *Alzheimer's / DementiaAnemiaAsthmaBirth DefectsCancerChronic FatigueChronic PainDiabetesEating DisorderEndocrine / Hormonal ProblemsGenital / Gynecological ProblemsHead InjuryHeart DiseaseHigh Blood PressureHigh CholesterolHIV Positive or AIDSKidney ProblemsLiver ProblemsLung DiseaseMigrainesNeurological ProblemsSkin DiseaseSleep ApneaStrokeThyroid DiseaseTuberculosisNone of these apply to meFamily Medical History -- Has anyone in your family ever experienced any of the following symptoms? Checklist: (check all that apply) *AnxietyADHDBipolarDepressionObsessions - OCDPanic attacksParanoiaSchizophreniaSuicideNobody in my family has experienced these symptomsPlease explain what family member and which problems they experienced: *Family Background and Childhood History: Where did you grow up? *Family Background and Childhood History: Were you adopted? *YesNoFamily Background and Childhood History: How many brothers do you have?Select012345678910Family Background and Childhood History: How many sisters do you have?Select012345678910Family Background and Childhood History: What is/was your father's occupation? *Family Background and Childhood History: Describe your relationship with your father? *Family Background and Childhood History: What is/was your mother's occupation? *Family Background and Childhood History: Describe your relationship with your mother? *Family Background and Childhood History: Did your parent's divorce? *YesNoDid your parent's divorce? If yes, how old were you? *Trauma History: Do you have a history of being abused? (check all that apply) *NoYes (check all that apply below)Emotionally AbusedSexually AbusedPhysically AbusedBy NeglectEducation History: (check all that apply) *GEDHigh School DiplomaAssociates DegreeBachelors DegreeMasters DegreeDoctorate DegreeOccupational History: Employment status (check all that apply) *EmployedUnemployedStudentDisabled/DisabilityPlease explain your current employment: *Occupational History: Have you served in the Military? *NoYes, RetiredYes, ActivePlease explain your military branch? *Relationship History: (check all that apply) *SingleMarriedPartneredDivorcedSeperatedWidowedDatingRelationship History: How many marriages have you had?Select012345678910Relationship History: Do you have children? *YesNoPlease explain your children's gender and age: *Legal History: Have you ever been arrested? *YesNoLegal History: Do you have any pending legal problems? *YesNoElectronic Signature (Type Full Name--Parent Guardian For Minor): *Date *MonthSelect month123456789101112DaySelect day12345678910111213141516171819202122232425262728293031YearSelect Year212421232122212121202119211821172116211521142113211221112110210921082107210621052104210321022101210020992098209720962095209420932092209120902089208820872086208520842083208220812080207920782077207620752074207320722071207020692068206720662065206420632062206120602059205820572056205520542053205220512050204920482047204620452044204320422041204020392038203720362035203420332032203120302029202820272026202520242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924Submit Online Form
