Demographics Hidden Source Patient's Full Name *
Person Completing Form *
Please indicate who is completing this form.
Click to Select Patient/Self Someone else Form Completer's Name *
Please enter the name of the person completing this form.
Form Completer's Relation to Patient *
Please indicate the relationship of the person completing this form to the patient.
Click to Select Spouse (husband or wife) Child (son or daughter) Sibling (brother or sister) Parent (mother or father) Other relative (in-law, cousin, aunt, uncle, etc.) Friend Other associate Patient's Date of Birth *
MM slash DD slash YYYY
Date of Patient's Appointment *
MM slash DD slash YYYY
Patient's Gender * Click to Select Female Male Transgender Patient's Handedness *
Please select the hand most often used for writing and other tasks.
Click to Select Left Right Patient's Ethnicity * Click to Select African American/Black Asian or Pacific Islander Caucasian/White Hispanic/Latino(a) Other Patient's Marital Status * Click to Select Divorced Married Single Widowed Patient's Employment Status * Click to Select Disabled or on medical leave Full-time Part-time Retired Unemployed Patient's Education Level * Click to Select Less than high school GED High school diploma Some college but no degree Associate's degree (2-year) Bachelor's degree (4-year) Master's degree Doctorate (M.D. or Ph.D.) Doctorate of Jurisprudence (J.D.) Other doctorate (e.g., DVM, OD, DSW, DPT) Medical History Medical Conditions *
Please check the box next to each condition for which a doctor has diagnosed or treated you, either now or in the past. Select the last option (none of the above) if you have none of these conditions.
Other Medical Condition(s)
If you have a medical condition not listed above, please enter it here.
Have you fallen in the past year? * Click to Select No Yes Do you feel unsteady when standing or walking? * Click to Select No Yes Do you ever use an assistive device, such as a cane, walker, or wheelchair? * Click to Select No Yes Nicotine Use *
Please consider cigarettes, cigars, pipes, and smokeless tobacco, as well as e-cigarettes.
Click to Select Current tobacco user Former tobacco user Never used tobacco regularly Alcohol Use *
Please consider beer, liquor, and wine.
Click to Select Currently consume alcohol Previously consumed alcohol, but quit Have never consumed alcohol Substance Use *
Please consider any recreational drugs (e.g., cannabis).
Click to Select Currently use recreational drugs Previously used recreational drugs Have never used recreational drugs Medications *
Please list all medications that you currently take. Enter NONE if you do not take any medications.
Please list all surgeries that you have had. Enter NONE if you have not had any surgeries.
Family Medical History Mother's Health *
Please list any medical or mental health problems your mother has (or had). If you were adopted, enter ADOPTED. If the information is unknown, enter UNKNOWN.
Father's Health *
Please list any medical or mental health problems your father has (or had). If you were adopted, enter ADOPTED. If the information is unknown, enter UNKNOWN.
If you have any brothers or sisters, please list any medical or mental health problems that any of them have (or had). If the information is unknown, enter UNKNOWN.
Mental Health History Psychiatric Medications *
Please indicate if you have ever taken medication for a mental health issue, such as depression or anxiety.
Click to Select Yes, currently Yes, in the past Never Psychological Therapy or Counseling *
Please indicate if you have ever participated in therapy or counseling for a mental health issue, such as depression or anxiety.
Click to Select Yes, currently Yes, in the past Never Alcohol Problems *
Please indicate if you have ever been diagnosed with or treated for alcohol problems.
Click to Select Yes, currently Yes, in the past Never Substance Abuse Problems *
Please indicate if you have ever been diagnosed or treated for substance abuse problems.
Click to Select Yes, currently Yes, in the past Never Psychiatric Hospitalization *
Please indicate if you have ever been hospitalized for a mental health issue.
Click to Select Yes No Suicide *
Please indicate if you have ever attempted suicide.
Click to Select Yes No