Gagandeep Singh, M.D., LLC – Personal History Form

Please answer these questions as pertaining to the patient – parents/caregivers may assist minors

Full Name *

Phone *

Email *

Please briefly describe the recent concerns which have led to your seeking this evaluation/treatment.

What are your three biggest stressors at this time?

Psychiatric History

Do you have a history of psychiatric issues, treatment, and/or hospitalizations?

Yes

No

If so, please compete the following:

Diagnosis
Dates Treated
By Whom
Where (Hospital/Office)

Have you taken psychiatric medications in the past or currently? If so, please list them here along with approximate dates, as well as whether they were helpful.*

*If you have an extensive history (more than 4 or 5 medications in the past), please use the Medication History Form which is also available on the website.

Are you currently receiving professional counseling or any kind of psychotherapy?

Yes

No

If yes, by whom?

Provider
Phone Number

Suicide Risk Assessment

Have you ever had feelings so bad that you have had thoughts that you didn’t want to go on, or that you might want to kill yourself?

Yes

No

*IF YES, please answer the following. If NO, please skip to the next section (Brief Screening Questions).

Is this unhappy feeling so strong you ever wish you were dead?

Yes

No

How often have you had these thoughts?

Has anything happened recently to make you feel like this?

On a scale of 1 to 10, how strong is your desire to kill yourself (10 = strongest desire)?

What would it take to move you one point down the scale?

Have you ever thought about how you would kill yourself?

Is the method you would use readily available?

Have you planned a time for this?

Have you ever tried to kill or harm yourself before?

Did things change as a result of these attempts?

Is there anything that would stop you from killing yourself?

If you could look into the future, what do you feel you could look forward to?

Brief Screening Questions

Are you having difficulty with sleep (hard to fall asleep or stay asleep, early awakening)?

Yes

No

Has your appetite been significantly greater or less than usual?

Yes

No

Are you bothered by hearing voices/sounds or seeing things others cannot see?

Yes

No

Do you have difficulty with focusing or following through on tasks?

Yes

No

Family Psychiatric History

If applicable, please list which relatives have struggled with which of the above issues.

Has any family member been treated with a psychiatric medication?

Yes

No

If yes, what medications and how effective were they?

Medical Information

Allergies

Current prescription medications for medical issues and how often you take them (if none, write ‘none’)

Current over-the-counter medications or supplements

Current medical problems

Past medical problems, hospitalizations or surgeries

Do you have any concerns about your health you would like to discuss with me?

Yes

No

Is there a family history of anything listed above? Please explain

Name of your primary health care provider

Provider Phone Number

Address

Date and place of last physical exam

Have you ever had an EKG?

Yes

No

Date of EKG

Have you ever had routine blood-work?

Yes

No

Date of blood-work

For women only

Date of last menstrual period

Birth control method

Are you currently pregnant or do you think you might be pregnant?

Yes

No

Are you planning to get pregnant in the near future?

Yes

No

How many times have you been pregnant?

How many live births have you had?

Developmental History

When your mother was pregnant with you, were there any complications with the pregnancy or birth?

Did you meet all developmental milestones on time (walking, talking, toilet training, etc.)?

Yes

No

If NO, please explain:

Substance Use

Have you ever been treated for alcohol or drug use or abuse?

Yes

No

If yes, for which substances?

If yes, where were you treated and when?

How many alcoholic drinks do you consume each week?

In the past three months, what is the largest amount of alcoholic drinks you have consumed in one day?

Cigarette use: Currently?

Yes

No

Cigarette use: In the past?

Yes

No

When did you quit?

How many per day on average?

For how many years?

Pipes, Cigars, or Chewing Tobacco use: Currently?

Yes

No

Pipes, Cigars, or Chewing Tobacco use: In the past?

Yes

No

What kind?

How often per day on average?

For how many years?

Have you used any street drugs in the past 3 months?

Yes

No

If yes, which ones?

If applicable, please list durations/dates for the use each substance

Have you ever felt you should cut down on your drinking or drug use?

Yes

No

Have people annoyed you by criticizing your drinking or drug use?

Yes

No

Have you ever felt bad or guilty about your drinking or drug use?

Yes

No

Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover?

Yes

No

Family Background and Childhood History

Were you adopted?

Yes

No

Where were you raised?

Did you grow up with both parents in the home?

Yes

No

If NO, please describe list your primary caretaker(s)

Did your parents divorce?

Yes

No

If so, how old were you when they divorced?

Please list your brothers and sisters and their ages:

What was your father’s occupation?

What was your mother’s occupation?

Describe your father and your relationship with him

Describe your mother and your relationship with her

How old were you when you left home?

Where you ever physically or sexually abused?

If so, please explain what happened and at what age(s)

Marital/Relationship History

For how long?

What is your significant other’s occupation?

Describe your relationship with your spouse or significant other:

Have you had any prior marriages?

Yes

No

If so, how many?

For how long?

Do you have children?

Yes

No

Ages of children

Describe your relationship with your children

List everyone who currently lives at home

Are you currently dating, sexually active, or in a relationship(s)?

Yes

No

Do you have concerns related to your sexual orientation?

Yes

No

Educational History

Did you attend college?

Yes

No

If yes, where?

What was your major?

What is your highest educational level or degree attained?

Occupational History

Are you currently

Working

Not Working

What is your occupation?

Where do you work?

How long in present position?

Legal History

Have you ever been arrested?

Yes

No

If yes, please explain

Do you have any pending legal problems?

Yes

No

If yes, please explain

Spiritual Assessment

Do you belong to a particular religion or spiritual group?

Yes

No

If yes, which religion or group?

Also, if yes, what is the level of your involvement?

Do you find your involvement helpful during this illness, or does the involvement make things more difficult or stressful for you?

More Helpful

More Difficult/Stressful

If you do not belong to a particular group, do you have any particular religious, spiritual beliefs or a philosophy of life that are particularly important to you?

Do your beliefs or philosophy of life affect how you to think or feel a about your illness?

Yes

No

If yes, how so?

As you face this illness, what activities do you use to help you cope, feel better, and heal?

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