HEALTH HISTORY QUESTIONNAIRE FOR TREATMENT RESISTANT DEPRESSION/ANXIETY

Name

Date of birth

Age

Weight

Address

Email *

Phone *

Referral Source

Relationship To Patient

Do you have a healthcare power of attorney? (If yes, please provide copy)

Yes

No

PSYCHOSOCIAL HISTORY:

Are you currently under the care of a mental health specialist (therapist, psychologist, psychiatrist?)

Yes

No

Name of specialist/specialty:

Frequency of Treatment: (weekly/monthly/yearly)

How long have you been under their care?

For how long have you experienced symptoms of depression or anxiety?

Have you been given a formal psychiatric diagnosis? If so, which ones?

Have you ever been hospitalized for depression or anxiety? If so, what is the date of your most recent hospitalization?

Do you have thoughts of suicide?

Yes

No

Have you ever attempted suicide?

Yes

No

Describe briefly what other work-up/evaluations you have had for your symptoms?

(e.g. neurologist/pain management consultation, sleep study, etc).

Military Service?

Yes

No

Include Combat?

Yes

No

Occupation

Marital Status

History of smoking/vaping

Yes

No

Do you drink alcohol?

Yes

No

Type/Frequency

Any history of illegal drug use-currently or in the past

(please describe more fully noting type, route, and frequency e.g. history of IV heroin use)

Are you currently being treated for any medical conditions?

If so, please list below (e.g. cholesterol)

Surgical History: Type of Surgery

Year

Please list the dose and frequency of your current medications:

Allergies?

Yes

No

Please list what type

Family History: Do you have any family members who have major medical issues or have a history of depression or anxiety disorder?

Father

Mother

Sibling

Please sign here that this information is true and accurate to the best of your knowledge.

Patient Signature

Clear

Date