CHRISTA L. HINES, M.D.

CLINICAL NEUROPSYCHIATRY

NEUROPSYCHIATRIC HISTORY / QUESTIONNAIRE

& REVIEW OF SYMPTOMS

Name: ____________________________________________________________ Date: _________________________________

DOB: _____________________________________________________________

Where did you hear about this practice? 

What is the primary reason for this visit? 

Major stressors/special concerns: 

What specific goals would you like to attain? 

When did your symptoms begin? 

Does/did anything seem to bring your symptoms on or make them worse?

What, if anything, makes your symptoms better? 

Please describe the type of symptoms you have, how severe they are, how long they last, when they seem to occur:

Prior History of Neuropsychiatric Illness?

Date Diagnosis Treatment Outcome:

Medical problems:

Date Diagnosis Treatment Outcome Physician:

Exercise: # times weekly how long? 

 Diet?

Herbal/Alternative Treatments & Results:

Surgery:

Date Diagnosis Surgery Outcome Name of Surgeon:

Name of Medicine Type of Reaction:

Allergies to Medications:

Current Medications you are taking:

Name Dose How Taken Benefits Side Effects

Personal & Family Medical History (please specify self or family member):

oHeart Disease _____________________________________________________

oHigh Blood Pressure________________________________________________

oGastritis _________________________________________________________

oGallbladder Disease_________________________________________________

oLiver Disease______________________________________________________

oEpilepsy__________________________________________________________

oLung Disease ______________________________________________________

oThyroid Disease____________________________________________________

oGlaucoma/Eye Disease_______________________________________________

oAlzheimer’s Disease _________________________________________________

oChemical Disease ___________________________________________________

oManic Depression __________________________________________________

oAnxiety/Panic Disorders______________________________________________

oPremenstrual Syndrome_______________________________________________

oSuicide/Suicide Attempt ______________________________________________

oHistory of Tatoos, piercings (#)? ________________________________________

oHepatitis C7________________________________________________________

oTreated? __________________________________________________________

oStroke ____________________________________________________________

oUlcers ____________________________________________________________

oColitis ____________________________________________________________

oKidney Disease______________________________________________________

oAllergies __________________________________________________________

oAsthma ___________________________________________________________

oDiabetes ___________________________________________________________

oHypoglycemia_______________________________________________________

oCancer _____________________________________________________________

oAlcoholism _________________________________________________________

oDepression _________________________________________________________

oPsychosis/Schizophrenia _______________________________________________

oObsessive Compulsive Disorder __________________________________________

oPostpartum Depression_________________________________________________

oHomicide/Homicide Attempt______________________________________________

oSelf Mutilation?________________________________________________________

Who is your obstetrician/gynecologist?

Name:

Address:

Phone: Fax:

OB/GYN History

Age at first period: 

 Do you have regular periods? 

Frequency/Duration of Periods: 

Birth Control: (IUD) Birth control pills (name or other)

# Pregnancies: ___________________ # Deliveries _______________________

# Miscarriages: __________________ # Abortion: _______________________

oC-Section oHysterectomy oTubal Ligation oIn Menopause For How Long? 

oPMS o Postpartum Related Illness

oPregnancy Related Illness oEspecially unusual/difficult delivery?

oPerimenopause Missing periods? Hot Flashes? 

oIn Menopause For How Long?

 oOn HRT?

oHistory of rape? 

oHistory of Sexual Abuse? What age?  How long? 

oWhat? oWho? 

oPhysical Abuse/emotional abuse? 

oSLS/PCOS: oFacial Hair oInfertility oDeep Voice

Sexual History: Are there any problems you are having in this area?

oLibido/Desire? oInability to orgasm? oLevel of enjoyment?

oHave you tried other things to help? oWhat? 

Response? 

Developmental Social History

Please comment on the following periods of you life and include anything you feel is significant, particularly any traumatic events, pervasive feelings, and also any description of yourself during these periods of your life.

Early Childhood

Adolescence

Adulthood

Relationships

Please comment on the following people and/or your relationship with them.

Please include anything you feel is important.

Father:

Mother:

Brothers and/or Sisters:

Spouse:

oNever married?

oYes oNo oNumber of times?

oDivorced? If yes, relationship with ex? 

Children:

Other Significant Relatives, Friends or Role Models:

Review of Neuropsychiatric Symptoms

Please read through all of the following sections carefully and check those symptoms which you are experiencing. Please feel free to make any comments in the space provided or in the margins. If you need more space, please use the reverse side of this page.

Review of Mood Disorder Symptoms

o Depressive & mania symptoms: 

o Dysthymia 2nd GMC: 

o How long has this been going on?

o Was there a trigger? 

o Lack of joy in life? 

o Able to function? 

o Feel at “half steam”? 

o Sleep disturbance: 

Decreased/Increased energy level: 

Difficulty concentrating: 

Difficulty making decisions: 

Decreased initiative or motivation: 

Changes in appetite or weight: 

Decreased/Increased sex drive: 

Feelings of hopelessness: 

Feelings of worthlessness: 

Family history of depression/mania:

Describe your mood (sad, anxious, depressed): 

Thoughts of suicide or hurting yourself: 

Don’t care if you live or die? 

Wish God would take you? 

Do you plant to carry these thoughts out? 

Recklessness/high risk activities: 

Changes in your behavior: 

Do you feel depressed or have others considered you to be depressed nearly every day? 

Have you lost or gained weight? (specify pounds): 

Do you have difficulty falling asleep, staying asleep, or waking up nearly every day? 

Do you feel fatigued or have no energy nearly every day? 

Do you feel worthless or guilty nearly every day? 

Do you have difficulty concentrating, thinking or making decisions nearly every day? 

Thoughts of suicide or hurting yourself: 

Do you have recurrent thoughts of hurting or killing yourself? 

Do you have a specific plan for killing yourself? If yes, please specify: 

Worse in am? oWorse in pm? oSame all day:

Worse before your period (women)? 

Worse after/during /before certain events: 

Trouble initiating things? 

Pain with it? 

Feel like very slow, can barely move? 

Previous episodes?

Worse in winter, without sunshine? 

Mania

oDoes anyone in your family suffer from manic depression or Bipolar Disorder? 

Do you feel an increase in your self-esteem to the point that you feel capable of anything or that somehow others are not as good as you are? 

Do you feel that you need less sleep or feel rested after only a few hours or have you gone extended periods of time without feeling a physical need to sleep? 

Do you feel, or have others told you, that you are more talkative than usual or do you feel a pressure to keep talking? 

Do you feel that your thoughts are racing? 

Do you feel easily distracted, do you feel your attention drawn to things in your environment that are not particularly important? 

Do you feel an increase in goal-directed activity, such as work, school, socially, sexually? 

Do you engage excessively, by your own standards or by others’ standards, in things that are pleasurable even if that may cause harm, such as buying sprees, foolish business ventures, sexual indiscretions?

Have you ever phone people during a time when you were feeling “wound up” during the night or early morning? 

Have people told you that you have periods in which you are argumentative, or do you feel that there are periods in which you are more argumentative?

Do people say you talk too much? 

Do you seem to annoy people? 

Do you interrupt other people while they are busy? 

Do sounds seem too loud? 

Do your moods swing or cycle between extremes? How often change? 

How long do episodes last? 

Perceptual Disturbance:

Do you feel, or do others feel, that you are having bizarre or unusual thoughts or ideas? 

Do you feel, or do others feel, that you are behaving in a bizarre or unusual way? 

Do you hear voices, see things, smell things, taste things, or feel things physically that others do not? Please specify. 

Do you feel that you are being watched or that people are trying to hurt you? 

Do you have feelings that you do not exist or that you are going to die? 

Do you feel that others are putting ideas into your head or are taking ideas out of your head? Do you feel others can read your mind? Or that you can read other people’s minds? 

Do you feel that you possess special powers or that you have special influence over things or people?

Do you make up words to express concepts of your own, concepts which others do not seem to understand? 

Do you feel that local or world events have a direct relation to you or that you have a direct influence on them? 

Do you feel that people you have never met or had contact with are communicating with you? 

Is this experience(s) consistent with your religion/spirituality? 

Things seem very loud? 

Voices tell you what to do? 

Other

See fuzzy shapes, etc. when you are tired, it is dark outside? 

People say you come and go? 

ANXIETY DISORDERS

Anxiety and Panic Disorder, GAD (generalized anxiety disorder), phobias, sd ind phobia and OCD

Do you experience episodes of shortness of breath or feeling smothered or unable to breathe? 

Do you experience periods of dizziness or feelings that you are going to faint? 

Do you experience episodes in which your heart pounds or races? 

Do you experience episodes in which you tremble or shake? 

Do you experience episodes in which you sweat profusely? 

Do you experience episodes in which you feel that you are choking or have difficulty swallowing? 

Do you experience episodes in which you feel nauseous or abdominal discomfort? 

Do you experience episodes in which you feel chest pain or discomfort? 

Do you experience episodes in which you feel numbness or tingling sensations? 

Do you experience episodes in which you feel chest pain or discomfort? 

Do you experience episodes in which things seem unreal or in which you feel unreal or question reality? 

During these episodes do you fear that you are going to die? 

During these episodes do you fear that you are going crazy or that you are going to do something uncontrolled? 

Feel tense, nervous most of the time? 

Chronic Muscle tension? 

Headaches? 

Grinding teeth? 

Heart racing? 

Afraid to leave house? 

Afraid of social situations? 

If you have answered yes to any of the above questions, do these episodes produce a great amount of fear in you? 

When did these symptoms first begin?

Are there situations or things which you avoid for fear of bringing this on or experiencing these symptoms? 

How often do you experience these feelings? 

How severe would you consider these feelings to be? 

What impact have these experiences had on your life? 

Obsessive Compulsive Disorder

Do you experience recurrent unwanted thoughts, images or impulses? 

Do you practice repetitive, ritualistic behaviors that you feel unable to stop doing (checking things, washing, cleaning)? 

Do your impulses, thoughts or rituals interfere with your daily life? How severely is your life affected? 

How much time and how often do you engage in the rituals or have the recurrent thoughts? 

Do you feel unable to stop the thoughts or refrain from practicing the rituals even though you know it is irrational or excessive? 

Are you ever able to refrain from the ritual or able to stop the thoughts, or do you eventually feel drawn or compelled to perform them no matter how much you do not want to? 

Are you ever able to refrain from the ritual or able to stop the thoughts, or do you eventually feel drawn or compelled to perform them no matter how much you do not want to? 

Some symptoms:

OBSESSIONS (recurrent intrusive thoughts)

COMPULSIONS (behaviors out of control)

Worry too much about the following:

Handwashing?

Gambling?

Germs?

Stealing?

Counting?

Hair pulling?

(Could be anything you can’t stop worrying or can’t)

Checking?

Nail biting?

(get your mind off)

Cleaning?

Lying?

Hoarding?

(Taking hours to do)

Perfectionist?

Stalking?

Simple things?

Overly preoccupied with a topic/person?

Phone calls?

Have to do it the hard way?

Spending?

History of Abuse or Trauma:

Emotional: 

Sexual: 

Physical: 

Violence Victim: 

Post-Traumatic Stress Disorder

o Are you in a current abusive relationship? 

Do you have recurrent dreams or nightmare about the event? 

Do you have flashbacks of the event? 

Do you feel you are withdrawing from people and/or life? 

Do the memories of the event intrude on your life? Comment. 

History of sexual, physical or emotional abuse/neglect? 

Have no vision of a future? 

Exaggerated startle response? 

PAIN HISTORY

Where? 

When? 

How severe? 

What helps? 

What doesn’t help? 

Pain meds: 

Alternative remedies: 

Impact on your life? 

What have you already tried: 

Results of above: 

Eating Disorder

Height: Lowest Adult Weight:

Weight: Highest Weight:

Desired weight goal: Ideal weight:

Do you eat large amounts of food in a short period of time? 

Do you try to lose or maintain weight by self-induced vomiting, laxatives, diuretics, diet pills or excessive exercise? 

Do you plan binges or hide food to eat later? 

Does your weight fluctuate ten pounds or more due to alternate dieting and overeating? 

Are you ever afraid that you might not be able to stop eating? 

Do you feel guilty about the way you eat? 

Have others expressed concern about your weight or eating habits? 

Are you spending large amounts of money on food? 

Is your menstrual cycle normal? Is it irregular? Has it ceased altogether? If so, for how long? 

Do you feel that you are overweight even when others tell you that you are not or even that you are too thin? 

Do you weigh yourself frequently? How often? 

Do you fear becoming overweight even while losing weight? 

o Do you have rituals for eating?

Do you wear baggy clothing or layers of clothing for reasons that may be related more to your weight than to fashion? 

Are you extremely sensitive to cold? 

Tried to diet? 

Success: 

Weight-loss meds: 

Crave certain foods? 

Postpartum Depression and Disorders

Have you ever experienced postpartum depression before? 

When was your delivery (if pregnant, your due date): 

Rate your desire to have this baby:

Very unsure 1 2 3 4 5 6 7 8 9 10 very sure

Rate your relationship with your spouse or partner:

Poor 1 2 3 4 5 6 7 8 9 10 excellent

Rate your relationship with your mother:

Poor 1 2 3 4 5 6 7 8 9 10 excellent

Are you experiencing a sense of confusion?

Do you have an obsessive preoccupation about harming your baby or of some harm coming to your baby?

Do you feel distant from your baby?

Do you feel sad, irritable or hyper most of the day for more than two weeks?

Do you feel restless? 

Do you feel guilty? 

If you feel you may be suffering a postpartum illness, please read the symptom sections on Depression, Mania, Anxiety, and Perceptual Disorders very carefully as many of the symptoms of postpartum manifest as symptoms of other disorders. Please also to be sure to obtain a New Mother History Questionnaire to fill out from our office.

Do you have a family history of above or Bipolar Disorder?

Whom 

What

Treatment

Delivery Complications? 

Severe sleep deprivations (can’t even sleep when baby is asleep)?

Recently moved? 

Personal history prior episodes: 

Support Network

Trouble breast feeding: 

Premenstrual Syndrome

Do you feel irritable, easily agitated and/or impatient a few days or more before your period? 

Do you have cramps that begin on the first day of your period? 

Do you feel depressed several days or more before your period? 

Do you have abdominal pain or discomfort which begins one day before your period? 

Do you feel exhausted, lethargic or tired for several days or more before your period? 

Do you always know when you are going to get your period even without looking at the calendar? 

Do you take a prescription drug for pain during your period? 

Do you feel weak and/or dizzy during your period? 

Do you feel tense and/or nervous before your period? 

Do you have diarrhea during your period? 

Do you have backaches several days or more before your period? 

Do you take aspirin for the pain during your period? 

Do your breasts feel tender and/or sore a few days or more before your period? 

Do you gain weight before your period? 

Are you constipated during your period? 

Do you experience a continuous dull aching during your period?

Do you feel nauseous during the first few days or so of your period? 

Do you have headaches a few days before your period? 

Do you experience periods of tearfulness for no apparent reason before or during your period? 

If you feel you may be suffering from premenstrual syndrome, please be sure to obtain a menstrual questionnaire to fill out from our office.

Note: For a diagnosis of PMDD, need to chart x2 months prospectively. What days of cycle have problems? (Must be done same time, every day for 2 months. Chart mood, etc. on paper.)

Irregular menses? 

Very heavy menses? 

No menses? 

Alcohol/Chemical Dependency

Do you use alcohol? If so, what kind, how much and how often?

What age started? 

Drug of choice? 

Do you use illicit drugs? If so, what kind, how much and how often? What age started? How obtained? 

Legal problems? 

Do you ever experience blackouts as a result of drug or alcohol use? 

Do you ever wake up after using drugs or alcohol and not remember part of the night before? 

Do your family and friends ever express concern about your drug or alcohol use? 

Have you ever been unable to stop drinking or using drugs in one period of use? 

Do you ever try to limit your use of drugs or alcohol to certain times of the day or certain places? 

Have you ever gotten into fights when drinking or using drugs? 

Do you ever sneak drinks or use drugs secretly? 

Have you lost friends or loved ones because of your alcohol or drug use? 

Have you ever been arrested in connection to your drug or alcohol use? 

Longest sober? 

$/month on drugs, alcohol? 

Been to AA? o Sponsor o Other treatment

Do you lie or make up alibis or excuses to cover up your drug or alcohol use? 

Do you ever drink or use drugs before noon? 

Have you ever experienced delirium tremens (DT’s), severe shaking, heard voices or seen things that weren’t there after heavy drinking or drug use? 

Is your drug or alcohol use creating a financial problem? 

Have you ever attended meetings for any organization related to drug or alcohol abuse? If so, what organization? 

Has anyone close to you ever sought counseling or help or attended support meetings because of your drug or alcohol use? 

o Ever use IV drugs? 

o Needles shared? 

o Treatment for drugs/alcohol? 

LEGAL HISTORY

Current or past legal problems? 

Served time? 

Where? 

NGRI

1CTST: 

RELIGIOUS/SPIRITUAL PREFERENCE?

EDUCATION

Highest level achieved? 

Grades? 

VOCATIONAL

Types of jobs you’ve held: 

Working now? 

When? 

Where? 

VETERAN

Yes (details): 

No

ANGER MANAGEMENT

What? 

How often and how long? 

What sets you off? 

Legal charges? 

Restraining orders? 

What do you do to express your anger safely? 

Have weapons? o What? 

ATTENTION DEFICIT DISORDER

Hyperactive and/or inattentive type

DSM-IV CRITERIA

Restlessness

Can’t sit still

Talkative

In motion

Concentration on one thing

Ability to put attention

Impulsivity

SLEEP DISORDERS

o Daytime sleepiness?

Hours/night normal?

Fall asleep during activities o Driving car?

Nap? oSnoring o Narrow airway passage?

Insomnia? o Overweight? o Early? o Mid? o Late?

For how long are you awake?

How many times/night does this happen?

Your sleep is off schedule?

Family/personal history of sleep apnea?

Narcolepsy?

SIDS?

CHILDHOOD ONSET ILLNESSES

o Major medical illness during childhood?

PERVASIVE DEVELOPMENTAL DISORDERS

Autism?

Aspergino?

Mental retardation?

Learning disabilities?

Eniesis/encopiusis

ADD? ADHD?

ODD?

OCD, other adult illnesses?

Tourettes?

Separation anxiety?

Reactive Attachment Disorder/Issues?

Other?

PERSONALITY DISORDERS?

o Cluster A o Cluster B o Cluster C

Please comment on anything you feel is relevant or significant that has not been covered.