Health Questionnaire

Name

First Name

Last Name

Phone

(###)

###

####

Age

Are you currently taking any medications, and if so, what?

Are you currently on SSRIs or any other antidepressants? Have you ever been on them? If so, what was the dosage and when did you discontinue?

Do you have any allergies?

Please specify.

Do you have any previous and/or current medical conditions?

Any family member medical conditions?

Have you had any major surgeries?

Please include year.

Have you been previously diagnosed and treated for your mental health?

Any family member mental conditions, including substance abuse?

Did you experience any trauma during childhood (psychological, emotional response to an event or an experience that is deeply distressing or disturbing)? What age?

Please check any current symptoms

Anxiety

Depression

Guilt

Avoidance

Panic attacks

Racing thoughts

Suspiciousness

Impulsivity

None of the above

Do you have a yoga, meditation, mindfulness, or similar practice? If so, for how long have you been engaged in it?

Are you currently receiving therapy? If so, what brought you to it?

Please include your therapist's name and contact information. This is for emergency purposes only.

Who is your emotional support network?

Please provide names, phone numbers, and email addresses. We require that someone close to you know you are doing this work.

Anything else we should know health-wise that would help us in better supporting you?

Please list any dietary restrictions (for ending meal)?