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Bradley University Health Services Counseling Center
Date _________
Name ________________________________ Birth Date _______________ ID # ___________
School Address _______________________ Class ______ Phone_______________________
Initial Evaluation Questionnaire
Please take time to complete this prior to your initial evaluation at the Student Health Center. This will allow the
physician/counselor to have a better understanding of the symptoms you are experiencing and your overall health.
1. If you have been experiencing problems with mood, please check if you have experienced any of the following:
___ depressed mood nearly every day, feeling sad or empty, tearful or irritable
___ decreased interest in activities that you normally enjoy
___ weight loss (not from dieting) or weight gain
___ decrease in appetite or an increase in appetite
___ insomnia, sleeping excessively, or awakening during the night
___ feeling lethargic (slowed down) or restless
___ feeling as if you do not have energy to do daily activities
___ feeling worthless, excessively guilty, or hopeless
___ decreased ability to concentrate or make decisions
___ thoughts of death or thoughts of suicide
___ any intentional self-injury or suicidal gestures (e.g. cutting on oneself, overdosing)
___ feeling as if you have more energy than normal
___ feeling as if you can do anything or feeling as if your mood is “too good”
___ others tell you that you are more talkative than usual or talking too much
___ feeling as if your thoughts are racing or moving fast
___ feeling more distractible than normal
___ increase in activity level—more than what is normal for you
___ excessively engaging in pleasurable activities such as buying sprees, sexual activity, drug or alcohol use, or
socializing
If you have experienced any of the above symptoms, how long have the symptoms been occurring?
___ < 1 month
___ 1–2 months
___ 3–4 months
___ 4–6 months
___ > 6 months
Have the symptoms recently changed? ___increased
___decreased
___ remained the same
Was the onset of symptoms associated with any life stressors?
___ breakup of a relationship ___ changes in family
___ family move
___academic stress
___ death of a loved one
___ parental divorce
___ physical illness (self) ___financial problems
___ physical illness (family) ___ conflict with roommate ___ legal/judicial problems ___ other_____________
Was the onset of symptoms associated with any of the following?
___ alcohol use
___ drug use ___ new medication
___ onset of new physical symptoms
___ prescription drug use
___ new herbal medication or any over-the-counter-medication
2. If you have experienced anxiety, have you experienced any of the following symptoms?
___ restlessness or feeling keyed up or on edge
___ being easily fatigued
___ irritability
___ difficulty concentrating or mind going blank
___ muscle tension
___ sleep disturbance
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Name________________________ Date of Birth:_____________ Bradley ID#:_____________
3. Have you experienced discrete episodes of anxiety with any of the following symptoms?
___ heart pounding or feeling as if your heart is racing
___ sweating
___ trembling or shaking
___ sensations of shortness of breath or smothering
___ feeling of choking
___ chest pain or discomfort
___ nausea or upset stomach
___ feeling dizzy, unsteady, lightheaded, or faint
___ feelings of unreality or feeling as if you are detached from oneself
___ fear of losing control or going crazy
___ fear of dying
___ numbness or tingling sensations (especially fingers or around mouth)
___ chills or hot flashes
How long do the episodes last?
___ 1-10 minutes
___10-30 minutes
___30-60 minutes
___ > 1 hour
4. Have you experienced any trauma (abuse, rape, motor vehicle accident, witnessing violence)?
___ Yes ___ No
If yes, circle which one of the above or indicate trauma here ______________________
Approximately when did this occur?__________________________________________
Has this event(s) led to any of the following?
___ recurrent or distressing dreams
___ intense distress when exposed to something that reminds you of the trauma
___ feeling internal feelings of anxiety (heart racing, sweating, etc.)
___ flashbacks during the day re-experiencing the event
___ feeling more detached from others
___ avoiding thoughts, feelings or conversations associated with the trauma
___ avoiding people, places or activities that arouse recollection of the trauma
5. Have you experienced compulsions (repetitive behaviors such as checking, hand washing, or mental
rituals such as counting or repeating)?
___ Yes
___ No
If yes, which of the following have you experienced?
___ excessive or ritualized hand washing
___ excessive cleaning of items
___ rereading, erasing, or rewriting
___ hoarding, saving
___ excessive or ritualized showering, grooming
___ checking locks, items, or other checking
___ counting objects, words, items
___ other _________________________________
If yes, please estimate the total amount of time spent each day on these compulsions:
___ < 10 minutes
___ 10-30 minutes
___30-60 minutes
___ > 1 hour
6. Have you experienced recurrent, intrusive thoughts (obsessions), impulses, or images that cause
distress or anxiety?
___ Yes
___ No
If yes, which of the following have you experienced?
___ concern with dirt, germs, illnesses
___ fear harm will come to self or others
___ fear of losing things
___ concern of offending religious objects
___ concerns of contamination
___ fear of unwanted impulses
___ repetitive, unwanted sexual thoughts
___ lucky/unlucky words, colors, numbers
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Name ____________________Date of Birth:________________ Bradley ID #______________
7. Have you experienced an ongoing and severe fear in social settings in which you fear that others are scrutinizing
you, or you fear that you will act in a way that will humiliate or embarrass yourself?
___ Yes ___ No
If yes, do you experience physical symptoms of anxiety when in the above social settings?
___ Yes ___ No
Does the fear cause you to avoid the above-described social settings?
___ Yes ___ No
8. Estimated current body weight ______ Highest adult body weight ______ Lowest adult body weight _______
Estimated current height ________
Are you satisfied with your current weight/body size?
___ Yes
___ No
Have you found yourself preoccupied with your weight?
___ Yes
___ No
Do you count calories?
___ Yes
___ No
Have you gone on eating binges that you feel you can’t stop? ___Yes
___ No
If female, when was your last normal menstrual cycle?____________________
Have you used any of the following to lose weight:
___ diet ___ vomiting ___ laxatives ___ enemas ___ “diet pills” ___ exercise ___ diuretics (“water pills”)
Do you exercise? If so, how many times per week?______________, for how many hours at a time?___________
9. Have you ever received any psychological treatment such as counseling or psychiatric treatment?
___ Bradley University Health Services
___ community counselor, if yes, who __________________
___ psychiatric hospitalization
___ partial hospitalization program
___ psychiatric evaluation (outpatient)
___ medication for anxiety or depression from a family doctor
___ substance abuse treatment (outpatient)
___eating disorder treatment (outpatient)
___ substance abuse treatment (inpatient)
___eating disorder treatment (inpatient or PHP)
10. Are you currently under the care of a physician for any medical problems?
___ No
___ Yes please list: ____________________________________ Doctor’s name: ___________________
Are you currently taking any prescription medication?
___ No
___ Yes please list: ____________________________________________________________________
Are you taking any over-the-counter or herbal medication or remedies?
___ No
___ Yes please list: _____________________________________________________________________
Have you had any past surgical procedures?
___ No
___ Yes please list: _____________________________________________________________________
Do you have any drug/food/environmental allergies?
___ No
___ Yes please list: _____________________________________________________________________
Do you have any developmental, learning or physical disabilities?
___ No
___ Yes please list: _____________________________________________________________________
11. Does anyone in your family (siblings, parents, aunts, uncles, and grandparents) have any of the following
disorders?
___ depression, if yes, who __________________________
___ bipolar (manic/depressive illness __________________
___ alcoholism/drug addiction ________________________
___ attention deficit/hyperactivity disorder _______________
___ anxiety, if yes, who _________________
___ panic attacks _____________________
___ suicide/suicide attempts _____________
___ schizophrenia _____________________
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Name ___________________________
Date of Birth:___________ Bradley ID #________________
12. Please list your immediate family members:
Mother _____________________ Age ______ Marital status _____ Occupation: _________________________
Father _____________________ Age ______ Marital status _____ Occupation: _________________________
Siblings ____________________ Age ______
____________________ Age ______
____________________ Age ______
Please note any recent changes in your family or any chronic problems:
________________________________________________________________________________________
13. Have you used/abused any of the following substances?
___ Alcohol, how much per week __________________
___ Cigarettes, how many/day ____________________
___ Inhalants (huffing), how many times _____________
___ Crack/Cocaine, how many times ________________
___ Adderall, Ritalin, or other stimulant medication
___Marijuana, how much per week _______
___LSD, how many times _______________
___Hallucinogenic mushrooms ___________
___Crystal meth/PCP/heroin ____________
___other prescription medications_________
If yes to any of above, at what age did you begin to use?______________________________________________
Has your use resulted in any problems in relationships?______________________________________________
Has your use resulted in any problems with school? _________________________________________________
Has your use resulted in any health problems? _____________________________________________________
Has your use resulted in any legal problems, such as a drinking ticket? __________________________________
14. What year are you in school?
___ freshman
___ sophomore
___ junior
___ senior
___ 5th year student
___ graduate student
15. Did you transfer in to this school? ___ No ___ Yes, if so, from what school ___________________________
Reason for transfer __________________________________________________________________________
Current living situation:
___ residence hall
___ fraternity
___ sorority
___ SAC/St. James apt. ___ off campus house/apt.
Do you have any roommates or housemates? ___ No
___ Yes If yes, how many?_____________________
Are you having any difficulties in your current classes? ___ No
If yes, which of the following symptoms are you experiencing?
___ poor concentration
___ test anxiety
___ skipping class(es)
___ decreased motivation to study
___ decline in grades
___ conflict with classmate(s)
___ Yes
___ distractibility
___ decrease in reading comprehension
___ conflict with professor
Have you had any changes in your status with the University? ___ No ___ Yes
___ dropped a class ___ changed majors ___ academic probation ___ violation of campus rules
16. Are you currently sexually active? ___ No ___ Yes
If yes, are you using any form of birth control? ___ condoms
___ spermicidal gel/foam ___ Nuva ring
___ birth control patch
___ birth control pills ___ DepoProvera
___ diaphragm
If female, any past pregnancies?
___ No ___ Yes
If yes, what was the outcome?
___ miscarriage ___ completed pregnancy ___ abortion
Any past or present sexually transmitted diseases ___ No ___ Yes, explain ___________________________
17. Have you had any legal difficulties?
___ No
___ Yes
If yes, which of the following?___ campus police
___ Peoria/State Police ___ moving violation
___substance abuse
___ DUI
___ other _________________
If yes, when did this occur? ___________________________________________________________________
Patient Signature: ____________________________________________________ Date: _______________
Mental Health Provider: _______________________________________________ Date: _______________
Thank you for taking the time to complete this questionnaire!
Revised 4.1.09