Self Assessment Form - Cbt Pinellas Page 2
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Loneliness: __________________________________________________________________________________
Stress/anxiety/panic attacks: __________________________________________________________________
Heart pounding/racing: _________________________________________________________________
Chest pain: ___________________________________________________________________________
Trembling/shaking: ______________________________________________________________________
Sweating/chills/hot flashes: ____________________________________________________________________
Tingling/numbness:_______________________________________________________________________
Fear of dying: ___________________________________________________________________________
Fear of going crazy: ____________________________________________________________________
Nausea/stomach problems: ______________________________________________________________
Phobias: ______________________________________________________________________________
Headaches: ____________________________________________________________________________
Nightmares: ___________________________________________________________________________
_________________________________
Other problems/symptoms: ___________________________
What types of previous therapy have you tried? With Whom? When? What was helpful and what wasn’t helpful?
____________________________________________________________________________
____________________________________________________________________________________
Who is your current prescribing psychiatrist? ____________________________How long have you been under this psychiatrist’s care?
_____________________. Please add any additional psychiatrist names? __________________
_____________________________________________________________________________________________
Current Psychiatric Medications, list:____________________________________________________________________
Helpful? Yes __ No __ Some ___
Historical Psychiatric Medications, list: _______________________________________________________________________
Helpful? Yes __ No __ Some ___
List all forms of Psychiatric Hospitalization stays: (partial or full hospitalizations, include Baker Act and/or Voluntary
admissions to Crisis Stabilization Units); please include dates and locations:
______________________________________________________________________________________________
__________________________________________________________________
Please list all medical conditions both current and historical: (Include Medications currently
prescribed):_____________________________________________________________________________________
______________________________________________________________________________________________
___________________________________________________
Please list the name/address of your primary care physician and most recent visit/check-up:
________________________________________________________________________________
Please add any other additionally relevant information:
______________________________________________________________________________________________
Beth Lewis, LMHC
(727) 463-1938 FAX (877) 240-7970
th
11380 66
St North Suite #135 Largo, Florida 33773
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