Print Name__________________________ Date of Birth ...



Your Signature __________________________ Date of Birth_________ Age_____

Briefly describe the problems that bring you in today (physical, health, and mental)

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Describe mood. (circle all that apply) Normal Depressed Anxious Irritable Sad

Angry Frustrated Variable

Are you able to enjoy activities that are usually enjoyable to you? Yes No

Describe your sleep. (circle one) Normal Disturbed

If disturbed, circle all that apply: Trouble falling asleep Trouble staying Asleep

Early morning awakening Nightmares

Sleepwalking/Talking Excessive movement

How long has your sleep been disturbed? _________________________

Do you feel rested upon arising? (circle one) Yes No Varies

Do you nap? Yes No If yes, how often in a given week? ______ How long? _____

How is your energy level on a typical day? (circle one) Normal Low High Variable

If you are chronically tired, please rate the severity (circle one) Mild Moderate Severe

Do you have chronic or near chronic pain? (circle one) Yes No

If yes, please circle the number that best describes your usual level of pain.

Low > 1 2 3 4 5 6 7 8 9 10 < High

Describe your appetite. (circle one) Normal Poor Too Good

If Poor or Too Good, for how long? ____________

Has your weight changed in the past year? (circle one) No change Gain Loss

If yes, by how much? __________

Below is a list of activities of daily living. Please place a check mark next to those activities that you are not able to do or that you cannot do without help.

Bathe or shower___ Others (Please List)

Dress___ ________

Toilet___ ________

Eat solid foods___ ________

Drink liquids without choking___ ________

Follow the story of a television show___

Use a cell phone ___

Use a television remote control ___

Surf the Internet___

Play video games___

Prepare a simple, cold meal (sandwich)___

Prepare a hot meal (soup)___

Prepare a full meal (meat, vegetables, starch)___

Use a microwave___

Use the stove___

Load a dishwasher or wash dishes___

Operate a dishwasher___

Do laundry___

Pay bills___

Drive___

Write a letter___

Buy stamps___

Grocery shop___

Manage medications___

Schedule doctor’s appointments___

Use a calculator

Read a book or magazine article____

Play a musical instrument___

Work a puzzle___

Care for children or grandchildren___

Did someone help you complete this form? (circle one) Yes No

If yes, please complete the next item without help.

Please write a sentence that makes sense in the space below. You may write any sentence you like but try to use correct spelling and punctuation.

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