Patient Health Questionnaire-9 (Phq-9) Template/form Gad-7 (Page 7 of 8) in pdf

Patient Health Questionnaire-9 (Phq-9) Template/form Gad-7 Page 7

Neal Brugman, Psy.D.

(720) 295-7605

Family Mental Health History:

In the section below, identify if there is a family history of any of the following. If yes, please indicate

the family member’s relationship to you in the space provided (father, grandmother, uncle, etc.).

Circle one

List family member(s)

Alcohol/Substance Abuse

Yes / No

Anxiety

Yes / No

Depression

Yes / No

Physical Violence

Yes / No

Domestic Violence

Yes / No

Schizophrenia/Psychosis

Yes / No

Suicide Attempt

Yes / No

Other Mental Illness:

Yes / No

____________________________

Alcohol/Drug Use:

Do you drink alcohol? Yes No

If so, how many nights per week do you drink? _________________

How many drinks per night (on average)? ______________________

Do you use any drugs recreationally

? Yes No

(including prescription medications)

If so, which drugs? ___________________________ How often? ___________________

Have you ever been treated for substance problems? Yes No

If so, what treatment (i.e. AA/NA, court mandated, rehab)?

_________________________________________________________________________________________________

Emergency Contact Information:

Name: _________________________________ Relationship to Client: ___________________

Address: ___________________________________________________________________

City:___________________________ State: _______ Zip Code: __________________

Phone: __________________________ email: ___________________________________

The Collaborative Center, LLC

Patient Health Questionnaire-9 (Phq-9) Template/form Gad-7 Page 7