Patient Health History Form

THANK YOU for allowing me to collaborate with you on your health. I’m honored to serve you. Please take a few minutes to answer the following questions. This information will help me understand how you’ve been doing lately. It will also give me a sense for what’s been going on in your life.
—David A. Frenz, M.D.

Really Big Picture

Looking back over the last week, including today, help me understand how you have been feeling by rating how well you have been doing in the following areas of your life, where marks to the left represent low levels and marks to the right indicate high levels.
(Please slide the buttons left or right with your finger or mouse)

 
Individually
(Personal well-being) 
Interpersonally
(Family, close relationships)
 
Socially
(Work, school, friendships)
 
Overall
(General sense of well-being)
Copyright © 2000, Scott D. Miller and Barry L. Duncan

Chemical Health

Which drugs or chemicals have you used in the past 30 days?
(Please mark all the boxes that apply)
How often did you think about or have urges to drink alcohol or use drugs?

How troubled or bothered have you been in the past 30 days by alcohol problems?

How troubled or bothered have you been in the past 30 days by drug problems?

Mental Health -- Part 1

Over the last 2 weeks, how often have you been bothered by any of the following problems?
(Please pick one letter for each row)

A = Not at all; B = Several days; 
C = More than half the days; D = 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 the opposite—being so fidgety or restless that you have been moving around a lot more than usual
Thoughts that you would be better off dead or of hurting yourself in some way
Feeling nervous, anxious or on edge
Not being able to stop or control worrying

Mental Health -- Part 2

Over the last 2 weeks, how often did you feel this way or have these things happen to you?
(Please pick one letter for each row)

A = Not at all; B = Several days; 
C = More than half the days; D = Nearly every day

 

Felt so hyper that you got into trouble
Felt so good or so hyper that other people thought you were not your normal self
Felt so irritable that you shouted at people or started fights or arguments
Thought about killing someone or physically hurting them in some way
Believed that people were spying on you, or that someone was plotting against you, or trying to hurt you
Heard things other people couldn't such as voices
Had visions when you were awake or saw things other people could not see

Physical Health

Over the last 2 weeks, how much did you feel this way or have these things happen to you?
(Please pick one letter for each row)

E = Not at all; F = A little bit
G = Quite a bit; H = Very much
Sedation, drowsiness or nodding off
Blurry vision
Dry mouth
Upset stomach or nausea
Hard stools (poop) or constipation
Loose stools (poop) or diarrhea
Trouble urinating (peeing) or emptying your bladder
Problems with sex
Shaking or tremor
Hot or cold flashes
Sweating too much

Over the last 2 weeks, did any of the following things happen to you?
(Please pick one option for each row)

Fainting or passing out
Falling down
Seizure

Reset Signature