Office of Louisa A. Parks, Psy.D.
Please fill out this questionnaire and bring it to your next appointment with Dr. Parks.
There are a lot of questions on this form. Please be patient and fill it out completely – it will help me to get to know
you without taking up your session time.
PATIENT INTAKE QUESTIONNAIRE
Name __________________________ Gender: M F Date of Birth __________________ Age _____________
Social Security # (optional) ____________________ Claim # _________________________ Telephone #
Street Address City State Zip
Referred by: _________________________________________________________________________________
Primary Care Physician: _________________________________________________________________
What is the main problem for which you are seeking treatment? _______________________________________________
ONSET OF PROBLEM
How long have you had your current problem (in years and/or months)? _______________________________________
What do you think is the cause of your problem?
Job related stress/trauma
Trauma other than job incidents
Cause not mentioned above ______________________________________________________________
FREQUENCY OF PROBLEM
How often do you have your problem (please check one)?
Constantly (100% of the time)
Frequently (75% of the time)
Intermittently (50% of the time)
Occasionally (25% of the time)
OTHER CURRENT HEALTH PROBLEMS
Please list any other current physical or mental health problems______________________________________________
Aside from your current problem, how is your general health (please check one)?
Excellent Minor health problems only Major health problems
Please list any medications you take currently: ____________________________________________________________
SUBSTANCE ABUSE OR DEPENDENCE
History of alcohol abuse or dependence? Yes No
Current alcohol abuse or dependence? Yes No
History of drug abuse or dependence? Yes No
Current drug abuse or dependence? Yes No
History of treatment for drug or alcohol abuse or dependence? Yes No
History of tobacco use? Yes No
Do you currently smoke? Yes No
How many total years have you smoked? __________
How many packs per day do you or did you smoke? __________
Please describe any history of mental health problems or treatment, including any medication taken: _________________
CURRENT LIVING SITUATION
Where do you live? __________________________________________________________________________________
Who are the other household members? __________________________________________________________________
What are your typical daily activities? ____________________________________________________________________
What is your current source of income? __________________________________________________________________
Please indicate your first language and cultural background: _________________________________________________
What is your highest level of education? ________________________________________________________________
What jobs did you have in the past? _____________________________________________________________________
What work are you currently doing, if any – for how long?
How would you rate your overall satisfaction with your current or most recent job?
0___ _1__ __2___ _3___ _4__ __5___ _6___ _7___ _8__ __9___ _10
totally dissatisfied totally satisfied
MOOD QUESTIONNAIRE (H.A.D.S.)
This questionnaire is designed to help your doctor know how you feel. Read each item and underline the reply which comes
closest to how you have been feeling in the past week. Don’t take too long over your replies; your immediate reaction to each
item will probably be more accurate than a long thought-out response.
I feel tense or ‘wound up’: I still enjoy the things I used to enjoy:
Most of the time… Definitely as much
A lot of the time.. Not quite so much.
From time to time, occasionally. Only a little..
Not at all Hardly at all…
I get a sort of frightened feeling as if
something awful is about to happen: I can laugh and see the funny side of things:
Very definitely and quite badly… As much as I always could
Yes, but not too badly.. Not quite so much now.
A little, but it doesn’t worry me. Definitely not so much now..
Not at all Not at all…
Worrying thoughts go through my mind: I feel cheerful:
A great deal of the time… Not at all…
A lot of the time.. Not often..
From time to time but not too often. Sometimes.
Only occasionally Most of the time
I can sit at ease and feel relaxed: I feel as if I am slowed down:
Definitely Nearly all the time…
Usually. Very often..
Not often.. Sometimes.
Not at all… Not at all
I get a sort of frightened feeling like
‘butterflies’ in the stomach: I have lost interest in my appearance:
Not at all Definitely…
Occasionally. I don’t take so much care as I should..
Quite often.. I may not take quite as much care.
Very often… I take just as much care as ever
I feel restless as if I have to be on the move: I look forward with enjoyment to things:
Very much indeed… As much as ever I did
Quite a lot.. Rather less than I used to.
Not very much. Definitely less than I used to..
Not at all Hardly at all…
I get sudden feelings of panic: I can enjoy a good book or radio or TV program:
Very often indeed… Often
Quite often.. Sometimes.
Not very often. Not often..
Not at all Very seldom…
PERCEIVED STRESS SCALE
The questions in this scale ask you about your feelings and thoughts during the last month. In each case, you will be asked to
indicate by circling how often you felt or thought a certain way.
0. Never 1. Almost Never 2. Sometimes 3. Fairly Often 4. Very Often
1. In the last month, how often have you been upset because
of something that happened unexpectedly? ……………………………………………… 0 1 2 3 4
2. In the last month, how often have you felt that you were unable to control
the important things in your life?…………………………………………………………… 0 1 2 3 4
3. In the last month, how often have you felt nervous and “stressed”?………………….. 0 1 2 3 4
4. In the last month, how often have you felt confident about your
ability to handle your personal problems?……………………………………………….. 0 1 2 3 4
5. In the last month, how often have you felt things were going you way?……………… 0 1 2 3 4
6. In the last month, how often have you found that you could not
cope with all the things that you had to do?…………………………………………….. 0 1 2 3 4
7. In the last month, how often have you been able to control irritations
in your life?…………………………………………………………………………………. .. 0 1 2 3 4
8. In the last month, how often have you felt that you were on top of things?…………. 0 1 2 3 4
9. In the last month, how often have you been angered because of things
that were outside of your control?…………………………………………………………. 0 1 2 3 4
10. In the last month, how often have you felt difficulties were piling up so high
that you could not overcome them?……………………………………………………….. 0 1 2 3 4
LIFE EVENTS SURVEY
Please mark each of the following events that have occurred within the last 12 months:
__Divorce 73 __Minor violations of the law (e.g., traffic tickets, disturbing the peace) 11
__Death of a spouse 100 __Death of a close family member 63
__Change in residence 20 __Major change in living conditions (e.g., building a new home, remodeling) 25
__Death of a close friend 36 __Major change in work hours or conditions 20
__Foreclosure on a mortgage or loan 30 __Marital reconciliation 45
__Change to a different line of work 36 __Major change in church, synagogue, or other religious activities 19
__Major change in eating habits 15 __Gaining a new family member (e.g., through birth, adoption, oldster moving in) 39
__Pregnancy 40 __Major change in number or arguments with spouse/partner (a lot more or less) 35
__Son and/or daughter leaving home 29 __Major change in responsibilities at work (e.g., promotion, demotion, transfer) 29
__Major change in sleeping habits 16 __Spouse/partner beginning or ceasing work outside the home 26
__In-law troubles 29 __Major business readjustment (e.g., merger, reorganization, bankruptcy) 38
__Major change in financial state 37 __Major change in number of family get-togethers 15
__Marriage 50 __Taking on a mortgage or loan for a minor purchase (e.g., car) 17
__Retirement 45 __Being fired from work 47
__Outstanding personal achievement 28 __Major change in health or behavior of family member 44
__Major personal injury or illness 53 __Revision of personal habits (e.g., dress, manner, associations) 24
__Detention in jail or other institution 63 __Taking on a mortgage or loan for a major purchase ( e.g., home, business) 30
__Marital separation 65 __Beginning or ceasing formal schooling 26
__Major change in social activities 18 __Major change in recreation 19
__Change in schools 20 __Troubles with your boss 23
__Vacation !3 __Sexual difficulties 39
HOW WELL DO THESE STATEMENTS DESCRIBE HOW YOU HAVE BEEN OVER THE PAST MONTH?
False Partly True Very True
1. I often feel sad or empty.
2. I have lost interest in most things.
3. I don’t enjoy the things that I am able to do.
4. I don’t laugh or smile much any more.
5. Things bother or annoy me more easily now.
6. I often feel like crying.
7. I don’t care much about other people any more.
8. I often feel like a failure.
9. I feel very bad about things I have done.
10. I don't feel much romantic or physical attraction
11. I don’t have much that I want to do.
12. I don’t have much to look forward to.
13. I often think about dying.
14. My life does not seem worth much.
15. I don’t care much whether I live or die.
16. Sometimes I don’t need any sleep. I stay up all night
and feel great the next day.
17. At times I talk very fast, so that my friends notice.
18. I am depressed, and my mood stays the same all day
long every day.
19. I make grandiose plans impulsively.
20. I often feel restless.
21. I often feel tired or slowed down.
22. I sleep too much.
23. It is hard for me to stay asleep.
24. It is hard to think, concentrate, or make decisions.
25. I eat too little or too much.
HOW WELL DO THESE STATEMENTS DESCRIBE HOW YOU HAVE BEEN OVER THE PAST MONTH?
False Partly True Very True
1. I seem to worry more than others.
2. I lack confidence.
3. I have so many worries that it is hard to relax.
4. I rarely feel safe and secure.
5. I feel a sense of fear or dread.
6. I often have feelings of intense fear or panic when
there is no real danger.
7. I often have fears about going crazy.
8. I have much stronger fears than most people about
certain things, places, or activities.
9. Because of fear, I avoid activities, things, or places
that most people would not avoid.
10. Bad memories or nightmares often bother me.
11. I am more jumpy or easily startled than others. I often have feel
12. I often try to avoid certain social situations because
they make me nervous.
13. I often worry about what others think of me.
14. Often I can't stop doing things over and over (like
counting, re-checking, washing, or cleaning).
15. Often I can't stop certain distressing thoughts from
running through my mind.
16. I have been too stressed to be able to sleep at all.
17. I am always confident.
18. I constantly feel startled.
19. I have no fears or worries.
20. I have fears that I am about to die or lose control.
21. I worry so much that it is hard to fall asleep.
22. My muscles are tense or tight from stress or worry.
23. I often sweat from stress even when it's not hot.
24. I am often so nervous that my breath or heart rate
seems to speed up or become uneven.
25. I am often so worried or tense that my appetite or
ability to digest food is affected.
PLEASE CIRCLE YOUR ANSWER TO THE FOLLOWING QUESTIONS AS BEST YOU CAN:
I have witnessed or been involved in a traumatic event: True False
Recurrent distressing dreams of the event: True False
Acting or feeling as if the traumatic event were recurring, such as a sense of reliving the experience, illusions,
hallucinations, and dissociative flashback episodes, including those which occur on awakening or when
intoxicated: True False
Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect to
the traumatic event. Physiological reactivity upon exposure to internal or external cues that symbolize or resemble
an aspect of the traumatic event: True False
Efforts to avoid thoughts, feelings, or conversations associated with the trauma: True False
Efforts to avoid activities, places, or people that arouse recollections of the trauma: True False
Inability to recall an important aspect of the trauma: True False
Markedly diminished interest or participation in significant activities: True False
Feelings of detachment or estrangement from others: True False
Restricted range of affect (e.g., unable to have loving feelings): True False
Sense of foreshortened future (sense that there is no future for you): True False
Difficulty falling or staying asleep: True False
Irritability or outbursts of anger: True False
Difficulty concentrating: True False
Hypervigilance (being “on guard” beyond what is needed for my job): True False
Exaggerated startle response (extra jumpy): True False