Name: ____________________________________________ Birth date: ____________
Nickname or other names you go by: _________________________________________
Marital Status:Single ___ Married___ Separated____ Divorced ____ Remarried ____ Partner _____
PRESENT LIVING SITUATIONS:
Where do you live:House___ Apartment ____ Room ____ Hotel ____Other (Specify) ________________
Do you own your home? ____ How long have you lived in Oregon? ________________
Who is living in your present household? _____________________________________
Please include information about any children or stepchildren not living with you. CURRENT CONCERNS
Please describe your reasons for seeking help at this time:
How long have you been troubled by these concerns?
PLEASE CHECK ALL INDIVIDUAL ITEMS THAT CONCERN YOU: Alcohol use ____ PLEASE CHECK ALL RELATIONSHIP ITEMS THAT CONCERN YOU: Affections ____
Holding other down ____ Sexual issues ____
Physical fighting ____ Verbal fighting ____
Having fun to together ____ Relatives ____
Please note any further individual or relationship concerns you might have that are not listed on the chart above. CHILDREN
If you have children, please check any area that concerns you regarding one or more of your children:Allergies ____
Health problems ____ Sexual concerns ____
Interference of ex-spouse ____ Temper tantrums ____
Drug or alcohol use ____ Physical or sexual abuse ____ Other _________________ Fears ____
Please note any other concerns you may have about your children. PERSONAL HISTORY
Where were you born? _____________________ Where did you grow up? ___________
How many places did you live before you finished high school? ____________________
How many schools did you attend through grade twelve? _________________________
How many brothers do you have? __________ How many sister do you have? __________
Circle # where you are in the birth order?
Under each # indicate male (M) or female (F):
Please mention any step or half brothers or sisters you have.
Were there any unusual circumstance regarding you conception or birth?
On the following timeline, please list what you feel are the five most significant events of your life:
Your birth ______________________________________________________________TodayWhat is/was your mother like? How did she treat you as a child?
What is/was your father like? How did he treat you as a child?
Were you raised by a step-parent or guardian? Please describe that relationship:
Please describe any deaths in your family while you were growing up; include your age at the time.
Did anyone in your family attempt or successfully commit suicide?
Where there any divorces in your family while you were growing up? Please explain and include your age at the time.
What were your favorite things to do as a child?
How did your parent(s) typically discipline you?
Please check any of the following that describes your family and home atmosphere when you were a child:Alcoholism____
Are you satisfied with your current social life? Briefly explain.
Please describe any organized or informal social groups that you are actively involved in.
When did you first begin dating? Were your early dating experiences positive?
Describe your relationship with your best friend, and how often you get together.
When was the last time you were together?
Which of the follow recreational activities do you enjoy?Biking____
If you are married, how long have you been married?_______________________
If you are married, how long did you know your spouse before getting married:________Your age at marriage:____________________
If you have any other past marriages, please list with approximate dates and your age:
What was the last grade in school (or degree) which you completed? ________________
Please note certificates, degrees or licenses which you have earned (include approximatedates):
Have you ever begun a training or academic program and stopped? If so, briefly describe the circumstances:
Describe any special training which you have had beyond your formal schooling.
How did you do academically in school (grade, middle, high)?
Have you ever been tested for a learning disability? Yes ____ No ____
Do you think you may have a learning disability? Please describe:
Have you ever been in the armed forces? Yes______ No______
If yes, what were the approximate dates of service? _____________ to _____________
Please describe your reasons for leaving the military and the type of discharge you received.
Describe your feelings about your military service or any special experiences that influenced you:
Have you ever had any legal difficulties? Yes _____ No _____
Any arrests? Yes ____ No____ Any convictions? Yes____ No____
Have you ever been in prison? Yes____ No ____
Name of your physician ______________________ Last exam: ___/___/___
Please list any surgeries you have had, including dates.
Please tell of any accidents or injuries you have had, including dates.
Please describe any head injuries, seizures or loss of consciousness you have had, including dates.
Are you taking medication for physical symptoms now?If yes, what medication are you taking?
Have you ever taken antidepressants? If so what was the medication & when were you taking it?
Check any of the following that apply to you:Back pain____
Don’t like to be touched____ Poor appetite____
Check if you feel:Overweight_____ underweight_____ concerned about eating habits_____
CHEMICAL SUBSTANCE HISTORY:
Family use: Does/did anyone in your family or origin, or in your immediate family, usealcohol or drugs (either prescribed or street drugs)? Yes____ No ____
If “Yes” who?_______________________________ For how long?_________________
Personal Use: What alcoholic beverages did/do you use?__________________________________________________________________________________________________How much? _______________________ How often?____________________________
When did you have your last drink?___________________________________________
What street drugs did/do you use? ____________________________________________
When did you last use? ____________________________________________________
Do you use nicotine? _____________________ How much daily?_________________
Caffeine? ________ How much daily? ______________________________________
Have you ever been in counseling or therapy before? Yes_____ No _____
If “Yes” when?________________ What were the issues you worked on?
Name of counselor/therapist: _______________________________________________
Have you ever been hospitalized for an emotional/mental disturbance? Yes____ No____
If ”yes” when? __________________ Please describe the issues and the results.
What medications have you been prescribed for mental health or emotional issues?
In the past month have you taken any medication for nervousness depression, insomnia, or pain? Yes____ No____ If yes, what medicine?
Have you ever attempted to commit suicide? Yes ____ No____ If yes, please explain how you attempted suicide and provide approximate date(s):
What is your current occupation? ______________________________________
On a scale of 1 to 10 what is your job satisfaction? Please circle one:
Please describe your family’s spiritual or religious atmosphere while your were growing up.
Are you currently involved with any church, religious or spiritual group or community? If so, please describe.
When did you develop your current spiritual beliefs?
Do your family and friends share your current beliefs?
Have you found your spiritual beliefs helpful or a hindrance?
Please indicate your general mood level for the last month by circling one of the numbers on the scale below:
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 Suicide ideas Depressed Average Good spirits Joyful
Now mark a “L” over one of the numbers to describe the low point of your mood during the last year. ANXIETY SCALE:
Please an “X” over one of the number on the 1 to 10 scale below to indicate your general level of anxiety or nervousness over the last month. The higher the number you indicate, the higher the level of anxiety, nervousness, and tension your are reporting. SEXUAL CONCERNS:
Please indicate if any of the following issues are of concern to you:
Please list three things you feel are your main strengths.
What would you say are your top three problems?
How do you feel that counseling can be helpful for you?
What are your future “dreams” for your life?
What if anything do you see prevents you from pursuing your life dreams?
Please add or emphasize any other information which you would like me to know so thatI may better understand you.
Information about your parents and their marriage:
Information about your parents and their relationship:
Information about your childhood, schooling, and friends:
Information about your current situation:
SINEMET® & SINEMET® CR Carbidopa/levodopa PRESCRIBING INFORMATION Refer to Summary of Product Characteristics (SPC) before prescribing Adverse events should be reported. Reporting forms and information can be found at . Adverse events should also be reported to MSD (tel: 01992 467272). PRESENTATION Sinemet 12.5 mg/50 mg Tablets contains 12.5 mg of anh
Section A: History Instructions: For each yes answer in section A, Circle the Point Score in that section. Total your score and record it in the box at the end of the section. Then move on to Sections B and C, scoring as directed. Have you taken tetracylines (Sumycin, Panmycin, Vibramycin, Minocin, etc.) orother antibiotic for acne for 1 month or longer?Have you ever taken other "bro