Print Name__________________________ Date of Birth ...
Your Signature __________________________ Date of Birth_________ Age_____
Briefly describe the problems that bring you in today (physical, health, and mental)
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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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