Do you consent to receiving text messages from Dr. Robinson? YesNo
Name:
Comment:
List Past Marriages (start and end date, years together, names & statement about the nature of the relationship/s): 1. 2. 3.
Children/Step Children (names/ages & brief statement on your relationship with the child/adult): 1. 2. 3. 4.
Siblings (name/age, if deceased: age and cause of death & brief statement about the relationship): 1. 2. 3. 4.
Cause of Death
If living, describe current relationship with her
Medical Problems:
Psychiatric Treatment:
Mother's drug / alcohol history:
Have any of your mother's blood relatives had any significant medical or psychiatric problems including drug or alcohol abuse/addiction, depression, anxiety, psychiatric hospitalization, suicide attempts?
Father's drug / alcohol history:
Have any of your father's blood relatives had any significant medical or psychiatric problems including drug or alcohol abuse/addiction, depression, anxiety, psychiatric hospitalization, suicide attempts?
Describe your childhood (Relationships with parents, siblings, others, school, neighborhood, relocations, any school/behavioral/problems):
Other Medical Specialists (name/phone/condition they are treating): 1. 2. 3.
Past and Present Medical Care (major medical problems, surgeries, injuries, illness):
Current Medications (Name, Dosage, Issue for which each medication is prescribed): 1. 2. 3. 4. 5.
Past / Present Psychotherapy / Neurofeedback History (start-end date, approx. # of sessions, helpfulness, name, city, ph# of therapist, reason treatment ended):
Psychiatric Hospitalizations (specify: month, year, number of days of each hospitalization, name of hospital, reason for hospital): 1. 2. 3.
Describe:
Has anyone ever told you they think you have a problem with alcohol or drugs? YesNo
Please Explain:
Have you ever felt guilty about your alcohol or drug use? YesNo
Have you ever felt annoyed when someone spoke to you about your alcohol or drug use? YesNo
Have you ever used alcohol or drugs first thing in the morning? YesNo
Have you ever tried to cut down on your drug/alcohol use and been unable to do so? YesNo
Have you been through any programs to treat substance abuse or addiction? YesNo
Please list programs: 1. 2. 3. 4.
C=Current Use P=Past Use Please describe use on line provided.
Alcohol CP
Nicotine CP
Marijuana CP
Cocaine / Methamphetamine CP
Opiates CP
Hallucinogens CP
Prescription sleeping pills or tranquilizers CP
Steroids CP
Other CP
Any problems staying asleep? YesNo
Any problems waking up? YesNo
On average, how many hours do you sleep at night? YesNo
History of sleep apnea YesNo
Do you snore YesNo
Do you or have you had sleep walking YesNo
Do you have frequent nightmares YesNo
Do you grind teeth during sleep YesNo
Any food allergies or sensitivities?
Are you on a restricted diet? YesNo
Caffeine consumption per day (chocolate, coffee, tea, ó †¸soda...):
Sugar consumption per day:
Describe your current bowel function: NormalConstipatedLooseDiarrhea
Describe your current exercise routine:
Do you consider yourself to be over or under weight? UnderweightOverweightNeither
What is your ideal weight?
How long have you struggled with your weight issues?
What weight loss measures have you tried?
Cultural and Ethnic Background:
Describe Yourself
Describe Your Strengths
Describe Your Weaknesses
Describe Your Friendships
Interested in Christian Counseling? YesNoMaybe, please tell me more about it
Please use this space to let me know anything else about yourself that you would like me to know: