WEL!STA R. Health Psychology Assessment r

IPart I. Demographics Today's Date Current Time

AgeName (Last) (First) (MI) Gender

o Female o Male

Race/Ethnicity

o African American/ Black o Asian American o Caucasian/White o Hispanic/Latino o Nat ive American o Other

Years of Education Were you ever in t he military?

0<12 o 12 (or GED) D B 0 14 o 15 o 16 017 0 18 o >18 o No o Yes (What branch?):

Email Address Relationship Status

o Single, Never Married o Divorced o Married o Separated o Widowed

Employment Status Disability Status

o N/A o Short-Term o Permanent o Retired o Work ing Full Time o Working Part Time o Unemployed

IPart II. Presenting Problem

W ho referred yo u for Health Psychology Serv ices?

Briefly describe t he problem yo u are hav ing t hat brings you here today:

How long have you been deal ing with this proble m ?

W hat are your expecta t ions regarding tod ay's visit?

Part III. Recent & Historical Medical Treatment

Please list the names and num bers of any m ed ical provide rs you have seen within the last year. If you have not seen one of the provider types listed, check the box marked N/A, for Not Applicable .

N/A Type Provider Nam e Phone N/A Type Prov ider Name Phone

D Primary Care D Psychiatrist

D Cardiologist D Neurologist

D Pulmonologist D Surgeon

D Oncologist D D Endocrinologist D

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WEL!STAR.Health Psychology Assessment ~

Please list the names and dosages of any medications you have taken within the last year. If you have brought a list of these medications wi th you to day, simply check the box next to "See Attached List" and proceed to Quest ion 1 below

o See Atta ched List

Name of Medication Dosage Frequency Prescribing Physician Current ly Taking?

DYes o No

D Yes DNo

D Yes o No

D Yes o No

D Yes o No

o Yes o No

o Yes o No

o Yes o No

DYes o No

o Yes o No

1 In the past, have you ever received treatme nt for mental health, substance abuse , or behav ioral problems? DY O N

If yes, when did you first receive treatment? ---~-------------------- -- -------------------------------- ---------------------------------------------------------------._.---------_.-----------------------------------

0 If N/A, check and proceed Describe why you sought treatment:

to question #2 below.

Were you ever hospitalized? 0 Y ON

2 Have you ever had a head or neck injury that caused you to lose consciousness or to feel dazed or confused? O Y O N

How many times? When was the most severe of these events? ----------------------------------------------------------------------------------------------------------------------------.--------------------------_.-----------------­

0 If N/A, check and proceed Did you ever receive medical treatment after any of these incidents? O Y O Nto question #3 below.

What symptoms did you have after the most severe event?

3 Do you have any known medical problems right now? 0 Y 0 N

If yes, list all here: ----------------------------------------------------------------------------------------------------_.._----- ---------~ ---. --..._-----------------------------_.---------.

If N/A, check and proceed -

to question #4 below.

4 Did you ever have any learning problems, difficulty paying attention , or behav ior problems as a child? OY 0 N

If yes, provide details below:

0 If N/A, check and proceed --------------------- --------------------------------------------------------------------------------------------------.~ ~-----_. --. _ ---------_.._._------------­------- ­_..

to Part IV.

2 I Breshears, R.E., & Chalfant , G.L. © 2010 . Permission to use grant ed to WeliStar Health System.

W EL!STA R. Health Psychology Assessment ~

Part IV. Health Status & Behaviors. Complet e all unshaded areas below.

Height Current Weight Weight 6 Months Ago Current Body Mass Index

Feet Inches Pounds Pounds kg/ m 2

Current Pain Assess m ent : Circle the number below tha t indicates how much physical pain you are experiencing right now

® ® ® ® @ ®<:X:) ~ ~ ~

0 1 2 3 4 5 6 7 8 9 10

No Pain Moderate Pain Severe Pain

Complete the table below regard ing your slee p hab its ove r the last week.

Time I usually we nt to bed at night

(approximate it necessary)

Time I usually fell asleep at night

(approximate if necessary)

Time I usually woke up the morning

(approximate it necessary)

Time I usually got out of bed to start the day

(approxima te it necessary)

~ III

"'C.:.:: ClI ClI

3:

:

III >III

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:

III >III

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III >III

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3:

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III "'C e ClI.:.:: ClI ClI

3:

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3:

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3:

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3:

:

Average # of times I woke up each night

Average # minutes it took me to go back to sleep after waking

(in minutes)

# of days I took a nap in the last month

Average # minutes per nap I t ook in the last month

(in minutes)

Weekday SE: Weekend SE: TOTAL SE:

Complete the table below regar d ing how m any tim es yo u engaged in the following behaviors in the last week:

# of Days Last Week

1. I ate breakfast 0 1 2 3 4 5 6 7 2. I ate lunch 0 1 2 3 4 5 6 7 3. I ate dinner 40 1 2 3 5 6 7 4. I used a CPAP or BIPAP machine 70 1 2 3 4 5 6

3 I Breshears, R.E., & Chalfant, G.L. © 2010. Permission to use granted to WeliStar Health System.

WEL!-STAR. Health Psychology Assessment ~

5. I set aside time to plan for the days, weeks, or months ahead 6. I woke up befo re I meant to, and I could not go back to sleep 7. I was so tired during some part of the day that I felt I was not functioning normally 8. My thoughts raced as I t ried to go to sleep at night 9. I kept track of how many calories I consumed throughout the day 10. I kept track of how many grams of protein I consumed throughout the day 11. I kept track of my daily "points" (a la Weight Watchers) 12. took a multivitamin 13. rode a bicycle to get some exercise 14. purposely to ok stairs instead of an elevator 15. took medic ations exactly as my physician prescribed them 16. used a treadmill, a recumbent bicycle, or a simi lar type of exercise equipment 17. used a pedometer, a body bug, or another way to track my health during th e day 18. participated in Yoga (or a similar activity) 19. used a fitness video (or TV show) at home to get some exercise 20. went to a gym or fitnesscenter to exercise 21. p-arti cipate d in a martial arts, kickboxing, boxing, or similar class 22. lifted weigh ts fo r the purpose of toning or building my muscles 23. engaged in continuous physical exercise for at least 15 to 20 minutes 24. engaged in cont inuous physical exerci se for at least 30 minutes 25. engaged in continuous physical exercise for at least 45 minutes 26. was intimate wit h a partn er

27. went for a walk or jog 28. spent t ime in prayer or meditat ion at some poin t during the day 29. ate at least one meal at a traditional or fast food restaurant 30. contacted a f riend or loved one by telephone, email, a social networking site, etc . 31. cleaned UR around the house or did yard work 32. participated in a hobby 33. attended a spiritual or religious service 34. took a bath or shower 35. flo ssed my teeth 36. used a journal 37. attended a social event 38. used a deep breath ing exercise to relax 39. spent time reading for pleasure 40. had a massage 41. spent 2 hours or more watching television 42. spent 2 hours or more on the computer that was not work related 43. Rart icipated in a sport 44. got 7 to 9 hours of sleep 45. attended a support group of some kind 46. listened to music t o relax 47. s~ent time with a friend or loved one

# of Days Last Week . 10 2 3 4 5 6 7

0 1 2 3 4 5 6 7 1 4 70 2 3 5 6

2 40 1 3 5 6 7 0 1 2 3 4 5 76

2 40 1 3 5 6 7 0 1 2 3 4 5 6 7-

40 1 2 3 5 6 7 40 1 2 3 5 6 7

0 1 2 3 4 5 6 7 1 70 2 3 4 5 6

4 6 70 1 2 3 5 0 1 2 4 73 5 6 0 1 2 3 4 6 75 0 1 2 3 4 5 6 7

70 1 2 43 5 6 0 1 2 3 4 75 6 0 1 2 3 4 6 75

1 70 2 3 4 5 6 1 2 4 6 70 3 5

0 1 42 3 5 6 7 0 1 3 4 62 5 7 0 1 2 3 4 5 6 7 0 1 2 3 4 6 75

20 1 3 4 5 6 7 0 1 42 3 6 75

4 70 1 2 3 5 6 10 2 3 4 5 6 7

0 1 42 3 5 6 7 0 1 2 73 4 5 6 0 1 2 3 4 5 6 7

20 1 3 4 5 6 7 0 1 2 3 4 5 6 7

40 1 2 3 5 6 7 0 1 2 3 4 5 6 7

0 1 2 3 4 75 6 1 2 4 5 70 3 6.­

2 6 70 1 3 4 5 0 1 2 3 5 6 74 0 1 2 3 6 74 5 0 1 2 3 4 5 76 0 1 2 3 4 6 75 0 1 2 3 4 65 7

4 I Breshears, R.E., & Chalfant, G.L. © 2010. Permission to use granted to WellStar Health System.

WEL!STAR.Health Psychology Assessment r-¥-

IPort IV. Emotional Assessment

For the following statements, circle the numbe r between a (not true) and 4 (very true) th at best describes your

experience over the last month

1. I have been feeling st ressed out 2. My' thoughts have seemed jumbled or scattered 3. I have been having more trouble concentrating than usual 4. I keep- reliving something bad that happened to me

5. My thoughts have been racing 6. I have had an unusually high energy level 7. I have been feeling down or depressed 8. I have been feeling anxious or nervous 9. I have been feeling irritable

10. I have heard voices that others cannot hear 11. I have purposely deprived myself of foo d 12. I have eaten an unusually large amount of food at times 13. I have seen t hings ot her people might think are unusual 14. I have had times when I felt out of control when eating

Not true Somew hat true Very true

0 1 2 3 4

0 1 2 3 4

0 1 2 3 4

0 1 2 3 4

0 1 2 3 4

0 1 2 3 4 0 1 2 3 4

0 1 2 3 4

0 1 2 3 4

0 1 2 3 4

0 1 2 3 4 0 1 2 3 4 0 1 2 3 4

0 1 2 3 4

Complete the tab le below with respect to any substances you currently use and/or have used in t he past.

Substance Check if

never used

Average Amount (#, $, OZ,

etc.) you have used each week during the last month

Age Substance Became a Problem

Approximate date of last use

Current ly Using?

Alcohol 0 o N/A o y O N

oy ONAmphetamines 0 o N/A

Methamphetamine 0 ON/A o y O N

Cocaine/Crack 0 ON/A o y O N

OtherStimulants 0 ON/A o y O N

oy O N Heroin 0 ON/A

Hallucinogens 0 ON/A oy ON

o y ONOpiates 0 ON/A

Marijuana 0 ON/A o y O N

O Y ONNicotine 0 =amt. per day ON/A Other: 0 ON/A O Y ON

IDate: I

(printed)

5 I Breshears, R.E., & Chalfant, G.L. © 2010. Permission to use granted to WeliStar Health System.