Total household income $ _____________ per year                                                                                                              

                                    Relationship to you ___________________________________________________

___   ___ Been involved with physical abuse

___   ___ Been involved with sexual abuse or incest

___   ___ Had problems (personal or family) from using drugs or alcohol

___   ___ Treatment by a psychiatrist (a medical doctor) --- if yes, who a  nd when

               _______________________________________

___   ___ Counseling with someone other than a psychiatrist --- if yes, who and when 

              ____________________________________

___   ___ Psychiatric hospitalization --- if yes, where, when and reason 

              _______________________________________________

___   ___ Been on medication for mental or emotional stress --- if now, who prescribes_______________________ 

                Name medication & dosage if taking now _________________________________________________

___   ___ Have used herbal supplements

___   ___ Eating problems (refusing to eat, bingeing, purging, etc.)

___   ___ Legal difficulties (been arrested, law suits, bankruptcy etc.)

___   ___ Major family problems

___   ___ Major personal problems

___   ___ Major career change

___   ___ Periods of unemployment or frequent job changes in last 5 years

___   ___ Nightmares or flashbacks

___   ___ Physical pain only at certain times or under certain circumstances

___   ___ Sexual problems   --   Describe_____________________________________

___   ___ Seriously contemplated or attempted suicide

___   ___ Exceptionally low self-esteem

___   ___ Problems overcoming certain feelings (circle those that apply) --- guilt, anger, 

___   ___ Problems because of impulsiveness

___   ___ Intentional cutting or otherwise hurting of self

___   ___ Panic attacks

___   ___ Hallucinations (seeing or hearing things)

___   ___ Trouble thinking clearly or disorientation (underline which ones --- not listening 

              forgetfulness, easily distracted)

___   ___ Head injury

___   ___ Difficulty with speech

___   ___ Sluggishness or low energy

___   ___ Weight loss not due to dieting

___   ___ Sleeping problems    --     Describe ________________________________________

___   ___ Memory problems

___   ___ Feeling faint or passing out

___   ___ Sudden personality changes or mood shifts

___   ___ Problems with personal relationships (non-family)

___   ___ Uncoordination

___   ___ Short attention span or trouble concentrating

___   ___ Long history of restlessness or being fidgety (including constant talking, interrupting, 

              sitting still in school or home)

___   ___ Nausea

___   ___ Headaches

___   ___ Excessive sweating

___   ___ Diarrhea

___   ___ High blood pressure

___   ___ Numbness or dizziness

___   ___ Being sickly a good part of your life

___   ___ Experienced several physical problems at once

___   ___ Unexplainable physical symptoms

___   ___ Preoccupation with a physical problem

___   ___ Threatening to kill someone

___   ___ Threatening to leave (e.g. run away, divorce, etc.)

___   ___ Decreased work performance

___   ___ Unable to perform daily duties due to stress

___   ___ Death of someone important within the last 3 years

___   ___ Loss of appetite

___   ___ Chest pain

___   ___ Choking or smothering sensations

___   ___ Learning disability

___   ___ Mental illness of any family members

___   ___ Complications at birth or slow mental or physical development as a child

___   ___ Trouble with self-control --- if yes, describe __________________________________________________________

___   ___ Racing thoughts

___   ___ Significant health problems --- if yes, describe ________________________________________________________

___   ___ Currently on medication for physical health problems --- name medications and physical problems

              _______________________________________________________________