COMPREHENSIVE MEDICAL QUESTIONAIRE
STRESS AND EMOTIONAL FACTORS
(Please answer the following questions as carefully as you can)
Do you consider your home life
Do you consider your work life
Do you consider yourself a tense or
Do you feel you manage stress well?
Are you taking any medications for
emotional or mental health concerns?
(Please list the medication and what
you take the medication for.)
Have you ever been in counseling with
a counselor, psychologist or
Are you currently seeing a counselor,
psychologist or psychiatrist?
Please circle the area of your greatest current concern or worry.
Briefly describe your current concern or worry
Please list any significant or traumatic life events. Significant/traumatic life events may include family
of origin or immediate family concerns such as drug/alcoholism, divorce/separation/death, or abuse
(physical, emotional, sexual). It may also include significant conditions such bouts of mental illness,
physical disability or genetic disorders.
Identify your position in your family of origin (e.g., are you a first born or second born, or only child?).