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(415) 966-0848
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Anxiety Online Questionaire
Answer the questions below to schedule an appointment for Anxiety Disorder Treatment.
Your privacy is important to us. All results are completely anonymous.
NAME
DOB
Section Divider
HOME ADDRESS
Okay to receive mail here
Section Divider
MAILING ADDRESS (IF DIFFERENT FROM ABOVE):
Checkboxes
Okay to receive mail here
Section Divider
CELL PHONE:
Checkboxes (copy)
Okay to phone
Okay to leave message
Section Divider
PREFERRED EMAIL ADDRESS: (PLEASE BE AWARE THAT EMAIL IS NOT A SECURE MEANS OF COMMUNICATION)
*
PREFERRED METHOD OF CONTACT:
Cell Phone
Home Phone
Email
Mail
Other
HOW DID YOU HEAR ABOUT THE CLINIC?
Medical Referral
Webpage
Psychology Today
Presentation
Friend or Family
Mental Health Referral
Others
RELATIONSHIP STATUS:
SEXUAL ORIENTATION:
RACE/ETHNICITY:
LANGUAGE(S) SPOKEN:
RELIGIOUS OR SPIRITUAL AFFILIATION:
ARE YOU CURRENTLY ACTIVE IN YOUR RELIGION?
YES
NO
PRESENTING PROBLEM
PLEASE STATE BRIEFLY WHAT HAS PROMPTED YOU TO SEEK TREATMENT AT THIS TIME?
HOW LONG HAVE YOU BEEN EXPERIENCING THIS PROBLEM(S)
PLEASE IDENTIFY ANY OF THE BELOW THAT ARE OF CONCERN AT THIS TIME (PLEASE CHECK ALL THAT APPLY):
Difficulty Sleeping
Relationship Concerns
Paranoia
Fatigue / low energy
Relationship Conflict
Loss or Grief
Procrastination
Infidelity
Alcohol or Drug Concerns
Burnout
Family Problems
Injury Recovery / Rehab
Motivation
Sexual Health Concerns
Legal Concerns
Academic / Work Concerns
Life Transition
Compulsive Behavior
Assertiveness
Infertility Concerns
Feelings of detachment / unreality
Trouble Concentrating
Physical Abuse / Assault
Intrusive Upsetting Thoughts
Stress Management
Sexual Abuse / Assault
Intrusive Upsetting Memories
Athletic Performance
Cultural Concerns
Cutting or Self Injury
Perfectionism
Sexual Orientation
Thoughts of Suicide
Self-Esteem
Gender Identity
Medical / Health Concerns
Decision Making
Personal Growth
Mood Swings
Learning Problems
Clarification of Values
Trauma
Phobias
Diet and Weight Loss
Depressed Mood
Panic Attacks
Disordered Eating
Anxiety
Nightmares
Shyness
Episodes of Manic Behavior
Anger Issues
Loneliness
Obsessive Thoughts
Feeling Guilty
Spiritual or Religious Concerns
Racing Thoughts
OUT OF THE ITEMS CHECKED ABOVE, PLEASE LIST YOUR TOP 3 CONCERNS IN ORDER OF IMPORTANCE:
HOW WOULD YOU RATE YOUR CURRENT LEVEL OF DISTRESS REGARDING THE CONCERNS YOU LISTED ABOVE?
MINIMAL
MODERATE
SEVERE
Item #1
Item #1 MINIMAL
Item #1
Item #1
Item #1
Item #1 MODERATE
Item #1
Item #1
Item #1
Item #1
Item #1 SEVERE
PLEASE RATE TO WHAT DEGREE YOUR CONCERN(S) AFFECT YOUR DAY-TO-DAY FUNCTIONING:
MINIMAL
Disagree
Neutral
Agree
MODERATE
Strongly Agree
Strongly Agree
Strongly Agree
Strongly Agree
SEVERE
Item #1
Item #1 MINIMAL
Item #1 Disagree
Item #1 Neutral
Item #1 Agree
Item #1 MODERATE
Item #1 Strongly Agree
Item #1 Strongly Agree
Item #1 Strongly Agree
Item #1 Strongly Agree
Item #1 SEVERE
EDUCATION & WORK HISTORY
HIGHEST EDUCATION COMPLETED:
Some High School
Bachelor’s Degree
High School Diploma
Some Graduate School
Some College
Master’s Degree
Associate’s Degree
Doctoral Degree
WHAT TYPE OF GRADES DID YOU TYPICALLY GET IN SCHOOL?
HAVE YOU BEEN DIAGNOSED WITH A LEARNING DISABILITY?
YES
NO
HAVE YOU BEEN DIAGNOSED WITH A LEARNING DISABILITY? (copy)
YES
NO
ARE YOU CURRENTLY EMPLOYED?
YES
NO
JOB TITLE / DESCRIPTION:
HOW LONG HAVE YOU BEEN AT YOUR CURRENT POSITION?
APPROXIMATELY HOW MANY JOBS HAE YOU HAD IN YOUR ADULT LIFE?
FAMILY HISTORY
WHERE WERE YOU BORN?
WERE YOU ADOPTED?
Yes
No
If yes, do you have any knowledge of your birth family?
WHERE DID YOU GROW UP?
HOW MANY TIMES DID YOU MOVE BEFORE YOU WERE 18 YEARS OLD?
DID YOUR PARENTS DIVORCE OR SEPARATE?
YES
NO
If yes, how old were you at the time?
PLEASE LIST THE (FIRST) NAMES AND AGES OF YOUR IMMEDIATE FAMILY MEMBERS (E.G., PARENTS, SIBLINGS,
CHILDREN, GRANDCHILDREN, GRANDPARENTS, SIGNIFICANT CARETAKERS):
NAME
RELATIONSHIP
AGE
QUALITY OF RELATIONSHIP
4
4
4
4
1
2
3
4
HAS ANYONE IN YOUR IMMEDIATE (PARENTS, SIBLINGS, CHILDREN) OR EXTENDED FAMILY (GRANDPARENTS, COUSINS, ETC.) BEEN DIAGNOSED WITH ANY OF THE FOLLOWING? OR DO YOU SUSPECT THAT THEY MAY HAVE ANY OF THE FOLLOWING?
Disordered Eating
Anxiety, fears, phobias
Attention problems or ADD/ADHD
Bipolar Disorder / Manic Depression
Addiction issues (alcohol, drugs, gambling)
Schizophrenia
Depression
Other
If you checked any of the above, please elaborate briefly:
MEDICAL HISTORY
DATE OF LAST PHYSICAL EXAM:
RESULTS OF EXAM:
HAVE YOU EVER BEEN HOSPITALIZED FOR A MEDICAL CONDITION?
Yes
No
If yes, please explain:
HAVE YOU EVER SUFFERED A SEVERE HEAD INJURY WITH LOSS OF CONSCIOUSNESS OR CONCUSSION?
Yes
No
If yes, please explain:
DO YOU HAVE CHRONIC PAIN?
Yes
No
If yes, please explain:
PLEASE LIST PAST AND PRESENT MEDICAL CONDITIONS, PROBLEMS AND/OR DIAGNOSES:
PRIMARY CARE PROVIDER (NAME, PHONE, ADDRESS):
PSYCHIATRIST / PSYCHOLOGIST / PSYCHOTHERAPIST (NAME, PHONE, ADDRESS):
PLEASE LIST ALL MEDICATIONS (AND DOSAGE) YOU ARE CURRENTLY TAKING (PLEASE INCLUDE PRESCRIPTION MEDICATION, OVER-THE-COUNTER MEDICATION, VITAMINS, ORAL CONTRACEPTIVES AND ALTERNATIVE REMEDIES):
PLEASE LIST ALL PSYCHOTROPIC MEDICATIONS YOU HAVE TAKEN IN THE PAST, IF ANY (PLEASE INCLUDE DOSAGE, DATES OF USE AND ANY SIDE EFFECTS):
HISTORY OF:
CHECK ONE:
Yes
No
IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE:
Seizure disorders
CHECK ONE:
Yes
No
IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE:
Respiratory disorders
CHECK ONE: (copy)
Yes
No
IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy)
Respiratory disorders (copy)
CHECK ONE: (copy) (copy)
Yes
No
IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy)
Respiratory disorders (copy) (copy)
CHECK ONE: (copy) (copy) (copy)
Yes
No
IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy) (copy)
Respiratory disorders (copy) (copy) (copy)
CHECK ONE: (copy) (copy) (copy) (copy)
Yes
No
IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy) (copy) (copy)
CHECK ONE: (copy) (copy) (copy) (copy) (copy)
Yes
No
IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy) (copy) (copy) (copy)
(copy)
CHECK ONE: (copy) (copy) (copy) (copy) (copy) (copy)
Yes
No
IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy) (copy) (copy) (copy) (copy)
(copy) (copy)
CHECK ONE:
Yes
No
IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy) (copy) (copy) (copy) (copy) (copy)
(copy) (copy) (copy)
CHECK ONE: (copy)
Yes
No
IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
(copy) (copy) (copy) (copy)
CHECK ONE: (copy) (copy)
Yes
No
IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
(copy) (copy) (copy) (copy) (copy)
CHECK ONE: (copy) (copy) (copy)
Yes
No
IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
(copy) (copy) (copy) (copy) (copy) (copy)
CHECK ONE: (copy) (copy) (copy) (copy)
Yes
No
IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
(copy) (copy) (copy) (copy) (copy) (copy) (copy)
CHECK ONE: (copy) (copy) (copy) (copy) (copy)
Yes
No
IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
(copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
CHECK ONE: (copy) (copy) (copy) (copy) (copy) (copy)
Yes
No
IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
(copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
CHECK ONE: (copy) (copy) (copy) (copy) (copy) (copy) (copy)
Yes
No
IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
(copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
CHECK ONE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
Yes
No
IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
(copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
CHECK ONE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
Yes
No
IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
(copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
CHECK ONE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
Yes
No
IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
(copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
CHECK ONE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
Yes
No
IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
(copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
CHECK ONE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
Yes
No
IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
(copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
CHECK ONE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
Yes
No
IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
(copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
CHECK ONE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
Yes
No
IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
(copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
CHECK ONE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
Yes
No
IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
(copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
CHECK ONE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
Yes
No
IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
(copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
CHECK ONE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
Yes
No
IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
(copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
CHECK ONE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
Yes
No
IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
(copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
CHECK ONE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
Yes
No
IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
CHECK ONE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
Yes
No
IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
MEDICAL HISTORY CONTINUED
WERE THERE ANY COMPLICATIONS AT YOUR BIRTH? (E.G., PREMATURE BIRTH, MEDICAL PROBLEMS)
Yes
No
If yes, please explain:
DID YOU EXPERIENCE ANY PROBLEMS IN YOUR EARLY DEVELOPMENT (E.G., LEARNING TO WALK, TALK, ETC.)?
Yes
No
If yes, please explain:
-FOR FEMALE PATIENTS
AGE OF FIRST PERIOD:
HOW MANY TOTAL PREGNANCIES HAVE YOU HAD?
HOW MANY TOTAL PREGNANCIES HAVE YOU CARRIED TO TERM?
WHICH BEST DESCRIBES YOUR MENSTRUAL CYCLE NOW?
Regular
Irregular
Pre-menopausal
Menopausal
Post-Menopausal
RELATIONSHIP HISTORY
AGE AT FIRST SIGNIFICANT ROMANTIC RELATIONSHIP:
TOTAL NUMBER OF MARRIAGES / LONG TERM (OVER 1 YEAR) RELATIONSHIPS:
IF YOU ARE MARRIED / PARTNERED, PLEASE BRIEFLY DESCRIBE YOUR RELATIONSHIP:
IF YOU ARE CURRENLTY SINGLE, DIVORCED, SEPARATED OR WIDOWED, PLEASE BRIEFLY DESCRIBE YOUR LAST LONG TERM RELATIONSHIP:
MENTAL HEALTH HISTORY
HAVE YOU EVER SOUGHT MENTAL HEALTH TREATMENT?
Yes
No
If yes, please complete the following about your past (or present) treatment experience(s)
Provider Name
PROVIDER CONTACT INFO:
APPROXIMATE DATES:
PROBLEM(S) ADDRESSED?
WAS TREATMENT HELPFUL?
Provider Name
PROVIDER CONTACT INFO:
APPROXIMATE DATES:
PROBLEM(S) ADDRESSED?
WAS TREATMENT HELPFUL?
HAVE YOU EVER BEEN HOSPITALIZED FOR A PSYCHIATRIC CONDITION?
Yes
No
If yes, please describe the circumstances of your hospitalization (how long, name of facility, dates):
HAVE YOU EVER BEEN ADMITTED TO RESIDENTIAL OR INTENSIVE OUTPATIENT TREATMENT?
Yes
No
