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(B) Family History
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Family History
Your full name
*
Todays Date
*
Father
Alive
Deceased
Current Age or Age at Death
Mother
Alive
Deceased
Current Age or Age at Death
Occupation
Occupation
*
Working
Student
Unemployed
Disabled
Retired
How long in present position?
What is/was your occupation?
Where do you work?
Have you ever served in the military? If so, provide the branch, when, and discharge type.
Relationship and Current Family
Are you currently
Married
Partnered
Divorced
Single
Widowed
How would you identify your sexual orientation?
*
Straight/heterosexual
Lesbian/gay/homosexual
Bisexual
Unsure/questioning
Asexual
Prefer not to answer
Other
What is your spouse or significant others occupation?
Describe your relationship with your spouse or significant other?
Have you had any prior marriages? If yes, how many?
*
Do you have children? If yes, list gender and ages:
*
List everyone who currently lives with you:
*
Family Background and Childhood History
Were you adopted?
Yes
No
Where did you grow up?
List your siblings and their ages:
What was your father and mothers occupations?
*
Did your parents’ divorce?
Yes
No
Describe your father and your relationship with him
*
Describe your mother and your relationship with her
*
How old were you when you left home?
Has anyone in your immediate family died?
Yes
No
When your mother was pregnant with you, were there any complications during the pregnancy or birth?
*
Yes
No
Trauma history
Have you sustained injury in an accident? Injury?
Type of accident and when?
Do you have history of being abused emotionally, sexually, physically or by neglect? If yes, Please describe when, where and by whom.
Tobacco history
Have you ever smoked cigarettes?
*
In the past
Currently smoking
Never
Pipe, cigars, or chewing tobacco:
*
Yes
No
In the past
Have you ever been treated for alcohol or drug use or abuse?
Yes
No
How many days per week do you drink any alcohol? What is the least number of drinks you will drink in a day? What is the greatest number of drinks you will drink in a day?
*
In the past 3 months, what is the largest amount of alcoholic drinks you have consumed in one day?
*
Have you ever felt the need to 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 had a drink or use drugs first thing in the morning to steady your nerves or to get rid of a hangover?
*
Yes
No
Do you think you may have a problem with alcohol or drug use?
*
Yes
No
Have used any street drugs in the past three months?
*
Yes
No
Have you ever abused prescription medication?
*
Yes
No
Check if you have tried the following:
Methamphetamine
Cocaine
Stimulants (pills)
Heroin
LSD or hallucinogens
Marijuana
Painkillers (not as prescribed)
Methadone
Tranquilizers/sleeping pills
Ecstasy
Other
If yes, how long and when did you last use?
Education
Highest grade completed?
Where?
Did you attend college?
Yes
No
What is your highest educational level or degree attained?
Is there any additional personal or family medical history that you would like to add?
Submit
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