Medical Form Patient Details First Name (required) Last Name (required) Email (required) Phone Number (required) Gender (required) MaleFemaleOther Date Of Birth (required) Street Address (required) City (required) State (required) Pet Details Pet name Pet Age Pet Breed Pet Weight Pet Gender MaleFemale Few Questions about your Medical Condition 1).During the past six months have you been frequently worried about big or small events in your life? TrueFalse 2). If you answered YES to Question #1, how frequently has your worrying caused anxiety or stress in the last six months? NeverRarelyUsuallyOftenAlways 3). If you answered YES to Question #1 above, Please describe. 4). Do people ever say you worry about things too much? TrueFalse 5). Do you think you worry about things too much? TrueFalse 6). Do you have difficulty controlling your worries or anxiety? TrueFalse 7). How long have you had difficulty controlling your worries in the past 12 months? NeverRarelyUsuallyOftenAlways 8). When worried do you frequently feel irritable or on edge for no apparent reason? TrueFalse 9). Do you often worry something bad is going to happen to you or someone close to you? TrueFalse 10). When worried do you have frequently have difficulty sleeping? TrueFalse 11). When worried do you have tensions or muscle aches? TrueFalse 12). Do you often become tired easily or experience a sudden unexplained loss of energy? TrueFalse 13). Does your worrying interfere with any major life activity? (Major Life Activities include, but are not limited to, caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, and working.) TrueFalse 14). If you answered YES to Question #13, please explain how your worrying interferes with your daily life activities. 15). Does your animal assist you in coping with your emotional or mental health symptoms? TrueFalse 16). If you answered YES to Question #15, please explain how? 17). Do you have any additional information you would like to add for the therapist to know about?
