To help us serve you better, please complete the following questionnaire and return in the envelope
provided. This information will help us better meet your needs. To contact the hospital Social Work
Department, call:______________________________________________________
Patient name:___________________________________ DOB:_______ Date:____________
Best phone number to reach you (work)____________________________________________
(home)___________________________________________(cell)_______________________
Email_____________________________________________
PERSONAL
Marital Status: Single
Committed Relationship
Married
Separated
Divorced
Widowed
Length of Marriage/Committed Relationship:_______ Name of Significant Other:___________________
Current Member(s) of Your Household:____________________________________________________
Please indicate if your parents are living or deceased. Mother_________ Father_____________
Please indicate number of siblings. Sister(s)_______
If you have children, please list them below:
NAME
AGE
________________________
________
________________________
________
________________________
________
________________________
________
________________________
________
Brother(s)___________
M/F
______
______
______
______
______
CITY/STATE
___________________
___________________
___________________
___________________
___________________
Please tell us about any other family members, friends, or work colleagues that play an important role in
supporting your treatment.
____________________________________________________________________________________
____________________________________________________________________________________
EDUCATION & EMPLOYMENT
Please circle your highest level of education:
Less than 12th grade
High School/GED
Some College
College Degree
Please circle your current employment status:
Not Employed
Retired
Disabled
Part-time
Post Graduate Degree
Full-time
Vocational Training
Stay at Home Parent
Other
Student
What type of work do/did you do?_________________________________________________________
FINANCIAL
Please indicate if you have applied for disability:
Short-term
Long-term
Social Security Disability
Please list any financial concerns you may have at this time.
____________________________________________________________________________________
INTERESTS & HOBBIES
What do you enjoy doing in your leisure time?_______________________________________________
What do you have planned to pass time while in the hospital?
____________________________________________________________________________________
COPING
What are some things you do to cope with the stress of your illness and treatment?
____________________________________________________________________________________
Are you comfortable with the ways in which you are coping at this time? Yes No
If no, please explain___________________________________________________________________
Is spirituality a source of support for you? Yes No If Yes, do you affiliate with a specific religion or
denomination?________________________________________________________________________
Have you ever attended a support group? Yes No
If yes, please tell us about your experience____________________________________________________
What concerns do you have about how your children or family members are coping with your illness and
treatment? _____________________________________________________________________________
Please rate your feelings of anxiety about treatment?
None 1 2 3 4 5 6 7 8 9 10 Extreme
Please rate your feelings of depression about treatment? None 1 2 3 4 5 6 7 8 9 10 Extreme
Are you currently being treated for any mental health needs? Yes
No If yes, please indicate method(s) of
treatment: Medication Individual Therapy Family Therapy Couples Therapy Other_____________
Have you been treated in the past for any mental health needs? Yes No If yes, what were you treated for
and what methods of treatment were used?______________________________________________________
If you are currently taking medication to address a mental health issue, please list:
Medication(s)_________________ Dosage(s)__________________ Prescribing Physician_____________
Have you ever experienced/witnessed any violence or abuse? Yes No If yes, please explain further if you
are comfortable doing so_____________________________________________________________________
HABITS
Substance
Tobacco
Caffeine
Alcohol
Marijuana
Other Drugs
Specific Type
___________
___________
___________
N/A
___________
Frequency of Use
_______________
_______________
_______________
_______________
_______________
Amount used Per day/Per week
__________________________
__________________________
__________________________
__________________________
__________________________
ADVANCE DIRECTIVES
Do you have a living will? Yes No
Do you have a durable power of attorney (health care power of attorney)? Yes No
If you wish, a copy of these documents can be kept on file with the hospital..
COMPLEMENTARY THERAPIES
Are you utilizing any complementary therapies at this time (herbs, relaxation techniques, etc.)? Yes No
If yes, please describe_____________________________________________________________________
OTHER NEEDS
Please list any agencies where you currently receive services________________________________________
Are you registered with Leukemia and Lymphoma Society Patient Financial Aid Program? Yes No
If you live 60 minutes or more from the hospital, do you need assistance with arranging lodging during your
treatment? Yes No
Please list any other information you would like us to know about you or any questions you may have.
_________________________________________________________________________________________
_________________________________________________________________________________________
THANK YOU!