SelectPsych
SELF-ASSESSMENT FORM
Name: _____________________________ Birth Date: __________ Age: ________ Date: ____________
Occupation: ________________________ Where do you work? _________________________________
Marital Status: (circle one) Single
Domestic Partner
Married
Separated
Divorced
Who referred you? _____________________________________________________________________
For what problem(s) are you currently seeking treatment? ______________________________________
_____________________________________________________________________________________
What are your current symptoms? ________________________________________________________
CURRENT PSYCHIATRIC MEDICATIONS (if any)
Medication
Strength
Dose
How Often?
Are you experiencing any medication side effects? ____________________________________________
PAST PSYCHIATRIC TREATMENT (if any - include any psychiatric hospitalizations)
With whom (or where)?
When?
Why?
PAST PSYCHIATRIC MEDICATIONS (if any)
Medication
Dose
When?
What happened?
SUBSTANCE USE HISTORY
Do you drink caffeinated beverages? Yes ___ No ___ How many per day? ___
Do you smoke cigarettes? Yes___ No ___ How many per day? ___ How many years? __ Quit when ____
Do you drink alcohol? Yes ___ No ___ How many drinks per day? ___
Ever been a problem? Yes__ No__
Have you ever used other substances? (circle all that apply) marijuana, sedatives, stimulants, cocaine,
crack, PCP, Opiates, Heroin, LSD, other: ___________________________________________________
SELF ASSESSMENT FORM
(CONTINUED)
FAMILY PSYCHIATRIC HISTORY
(e.g., depression, anxiety, bipolar disorder, schizophrenia, alcoholism, hospitalizations, suicides)
Family member
Diagnosis
Treatment if known
MEDICAL HISTORY
Primary Care Physician: __________________________________________________________________
Medication allergies: ____________________________________________________________________
Last physical exam: ___________________________ Last lab work: ______________________________
Do you currently have any physical complaints?_______________________________________________
______________________________________________________________________________________
MEDICAL CONDITIONS AND CURRENT MEDICATIONS
Medical Condition
Medication
Dose
SOCIAL HISTORY
Where were you born and raised? __________________________________________________________
Highest level of education: ____________________________ Degree: ___________________________
Religion you were raised in: _________________________ Do you still practice? ___________________
Whom would you identify as your support system? ____________________________________________
ADDITIONAL QUESTIONS
What do you see as your strengths? _________________________________________________________
______________________________________________________________________________________
What would you ideally like to gain from treatment? ____________________________________________
______________________________________________________________________________________
Is there anything else we should know? ______________________________________________________
______________________________________________________________________________________
___________________________________
Signature
3/10/12