Has anyone in your family (blood relative) suffered from emotional, problems, nervous problems, depressions or other stress conditions? If so, please list the family member(s) and briefly describe the problem.
Has anyone in your family (blood relative) had problems with alcohol? If so, please list the family member(s) and briefly describe their problem
Has anyone in your family (blood relative) had problems with drugs? If so, please list the family member(s) and briefly describe the problem.
Do any medical problems run in your family? If so, please list briefly and describe these problems
Has anyone in your family ever attempted or committed suicide? If so, please list briefly and describe the incident.
If deceased, what was the cause of death?
What type of work did he do?
If deceased, what was the cause of death?
What type of work did she do?
Please list in order all the cities and states in which you have lived and include the number of years (or age) you resided in each city.
Did you suffer from any traumatic experiences as a child? If so, please describe these.
If so, please specify which child(ren) and explain the problem(s)
Please list your jobs, starting with the first job and going through to your most recent job. Also list next to each job how many years you were employed in that position.
Do you use or have you used drugs? Have you quit using drugs? If you still use drugs, complete the following list:
Have you ever been involved in a substance abuse, alcohol treatment or detoxification program? If so, please describe when and where.
Please list any medical problems that you have and when these conditions were diagnosed or discovered.
Please list all operations that you have had starting with any operations that you may have had as a child. Also list when these procedures were performed.
Please list any allergies to medications that you have experienced.
Have you ever had a head injury in which you were knocked unconscious? If so, please list your age at the time of the injury and how long you were unconscious.
Please list all your present medications. Include the amount (milligrams), how often you take it, how long you have taken it and the doctor who prescribes it.
Have you ever received any psychiatric, psychological, emotionaltreatment/counseling or hospitalization in the past? If so, list the year(s) or your age when this treatment was provided and how often the treatment was provided.
Have you ever been prescribed psychiatric medicines (like an antidepressant or nerve pill?) If so, list the year(s)/age, medication, and how often you take the medication
