{this.} Name: ____
darwood___
Gender: __
m_________ Ethnicity:__
glen__ Sexual Orientation:__
strate________
Are you sexually active? _
naw__________________ Marital Status:_
nope______
Do you have children?__
nope______ What are your religious beliefs?_
dunno_____
What are your family’s religious beliefs?____
bullshit________________________
What is you occupation?__
soulless lump_________________________________
Do you require language assistance with Glennish?__________________________
Any general information about family members or your relationships with others
that may be relevant to mental or physical health issues? ____________________
Does anyone in your immediate or extended family have a history of mental health
or substance/alcohol abuse issues?___
yup_______________________________
Substance Use History
Do you drink alcohol? YES/
NO # drinks/week:__
can't__________________
If yes: Have you ever felt you should cut down on your drinking? YES/NO
Have people annoyed you by criticizing your drinking?
YES/NO
Have you ever felt bad or guilty about your drinking? YES/
NOHave you ever had a drink in the morning to steady your nerves or get rid
of hangover symptoms (eye-opener?)
YES/NO
Do you smoke cigarettes or use other tobacco products? YES/
NO # per day___
Please check the following drugs that you have used in the past or currently use:
Cannabis_
X Barbiturates_
X Benzodiazepines (Vaylor, Amavar, Prosec)_
?LSD (acid)_
X Mescaline_
? PCP_
X Mushrooms_
X Caffeine
Amphetamines (Attentor, Focalvine, Paramol, etc.)_
X Ecstasy_
X Cocaine_
XGuarana__ Khat__ Pseuodoephedrine_
? DXM__ Codeine__
Heroin
Hydrocodone_
X Oxycodone_
X Morphine_
X Opium_
XInhalants_
X Others_____
?__________________________________
Any other drugs, herbs, vitamins or supplements: _________________________
Describe the frequency of use and the reason for use of the above drugs: ________
___
mostly heroin, kinda a lot, quit tho______________________________
How many hours do you sleep during a 24 hour period?__all day, some nights_
Do you have any trouble falling asleep?__
nope____________________
Do you have any trouble staying asleep?___
sometimes________________
What are your normal bed and wake times? __
dunno____________
What do you do for fun?__
I don't fuckin know__________________
Have you ever been in therapy, substance abuse counseling, or taken psychiatric
medication in the past? If so, please give details of medications tried, responses and
side effects, and reasons for counseling. __
who cares___________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Have you ever been hospitalized for mental health or substance abuse issues? If yes,
Why and for how long were you inpatient? __
no_______________________
________________________________________________________________
________________________________________________________________
Any past or present suicidal thoughts, plans or attempts?
YES/NO
Explain___
why are you so hot to be alive?________________________
________________________________________________________________
Any past or present thoughts about harming someone else?
YES/NO
Explain______________________________________________________
Did any of the following events occur during your childhood or adolescence?
(Check all descriptions that apply)
Physical Abuse_
X Verbal Abuse_
X Witness to violence_
XTeasing/Bullying_
X Sexual abuse or rape__ Medical Problems__
Rigid religious way of life__ Trauma (fire, crime victim, natural disaster)__
Drug/alcohol abuse_
X Extreme Parental Control/Pressure__
In the past and/or currently, have you ever experienced and problems with any of
the following symptoms or behaviors: (Check all that apply)
Self-harm (cutting, burning, overdosing)__ suicidal thoughts, plans or attempts_
XUsing illegal or prescription drugs_
X Excessive use of alcohol_
X blackouts_
XMemory disturbances_
X Self-induced vomiting__ Laxative Abuse
Odd or irrational behavior
Depression_
X Nervous Tics__
Impulsiveness__ obsessions/compulsions/rituals__ restrictive eating__
Aggressive or violent behavior__ legal problems_
X anxious avoidance__
Seriously risky behavior_
X Promiscuity__ appetite/weight loss_
XInability to sleep for more than 48 hours straight_
X Insomnia/sleep disturbance_
XLoss of interest in sex (if sexual)_
X Concerns about sexual identity__
Hallucinations (hearing voices, seeing or hearing things others do not see)_
XAny additional symptoms of concern?:___________________________________
___________________
I wanted to say something funny___________________
_________________________________________________________________
_________________________________________________________________