Patient identification
First name:
Last name:
Birthday:
Phone number:
Email:
Street address:
Postal Code:
City:
Province / Territory:
Healthcare number (e.g. RAMQ)
Healthcare province:
Healthcare number expiration date:
Emergency contact name:
Emergency contact phone number:
Emergency contact email:
Emergency contact relationship:
Social history
Home situation (choose ):
1. Living alone
2. Living with roommates
3. Living with spouse / long term partner
4. Living with parents
5. Living with children
6. In a group home
7. Without a stable home
8. Other ______
Relationship status (choose one):
1. Married
2. Stable long term partner
3. Single
4. Widow / widowed
5. Several long term partners
6. Other _____
Do you have any dependents, including pets? [Yes / No]
If you have dependents, please indicate who (check all who apply):
1. Children below 18
2. Dependent children above 18
3. Dependent parents
4. Disabled spouse
5. Pets
6. Other ______
Do you have any children?
1. No
2. Yes -- please indicate how many: ___
Where were you born? ___________
Where did you grow up? (List all locations and the years)
Location: Age arrived: Age departed:
1. _______ _______ _________________
2. _______ _______ _________________
3. _______ _______ _________________
4. _______ _______ _________________
5. _______ _______ _________________
If you were not born in Canada, when did you come to Canada? ______
How many siblings do you have? _____
If you have siblings, how many were older than you? _____
You were raised by
1. Both parents
2. One parent
3. Grandparents
4. Other _____
5. A mixture of the above: ______
What was the highest education degree you obtained? _______
Occupation history
Are you currently
1. Employed
2. On leave from employment
When did you go on leave? ______
What was the title of your current job? ______
How long have you been at your current job? ____
What is your current leave status?
1. Sick days
2. Employment insurance
3. Vacation
4. Medical leave
Is this the first time you have been on leave from this job? Y/N
If this is not the first time, please list the dates, durations, and reasons of your previous
leaves from your current job:
Date: Duration: Reason:
1. _______ _______ _________________
2. _______ _______ _________________
3. _______ _______ _________________
4. _______ _______ _________________
5. _______ _______ _________________
Did you have jobs prior to the current one? Y/N
If yes, please tells us about your longest employment within the last 10 years, that is prior to
your current employment:
Title of the your longest prior job: ___________
From when until when did you work there: __________ to __________
Did you take any leaves from your longest prior job? Y/N
If yes, please list, to the best of your ability, your leaves from your longest prior job:
Date: Duration: Reason:
1. _______ _______ _________________
2. _______ _______ _________________
3. _______ _______ _________________
4. _______ _______ _________________
5. _______ _______ _________________
In the last 10 years, were you unemployed and not going to school for any period of time?
Y/N
If yes, please list, to the best of your ability, your periods of unemployment
Date: Duration: Reason:
1. _______ _______ _________________
2. _______ _______ _________________
3. _______ _______ _________________
4. _______ _______ _________________
5. _______ _______ _________________
Current treatments
Please give us a list of all your current mental health medications:
Medication name: Helpful? Side effects:
1. _______ _______ _________________
2. _______ _______ _________________
3. _______ _______ _________________
4. _______ _______ _________________
5. _______ _______ _________________
6. _______ _______ _________________
7. _______ _______ _________________
Please give us a list of all your other medications:
1. _______
2. _______
3. _______
4. _______
5. _______
6. _______
7. _______
Do you have any allergies to medications? [Y/N]
If yes, please tell us what medications you are allergic to:
1. _______
2. _______
3. _______
Do you currently have a family doctor? [Y/N]
If yes, please give us the name of your family doctor: _________
Do you current have a therapist? [Y/N]
If yes, please give us the name of your current therapist ________
Since when has this person been your therapist? ________
How often do you see your therapist? [Weekly, once every two weeks, once a month, other
____]
Do you currently attend group therapy? [Y/N]
If yes, please tell us what organisation or centre administers the group therapy?
Since when have you been doing group therapy? _____
How often do the groups run? [Weekly, once every two weeks, once a month, other ____]
In the past year, have you received any mental health treatment other than therapy and
medications? (E. g. ECT, ketamine, rTMS)? [Y/N]
If yes, please tell us which:
1. _______
2. _______
3. _______
Are there are professionals currently involved in your mental health (e.g. occupational
therapist, mental health nurse, social worker)? [Y/N]
If yes, please tell us which:
Profession Name Private or public?
(E.g. OT, nurse)
1. _______ _______ _________________
2. _______ _______ _________________
3. _______ _______ _________________
History
Psychiatric history
Have you ever been seen for mental health reasons in the Emergency Room or a crisis
centre? [Y/N]
If yes, how many times in the last five years have you been in the ER or a crisis centre?
[1, 2, 3, 4-5, 5-10, more than 10]
If you have had ER or crisis centre visits in the last five years, please write, for the last three
visits, as best as you can remember:
Visit 1
Date:
Reason for the visit:
Which hospital / crisis centre?
Were you hospitalised?
If so, how long were you hospitalised for?
Visit 2:
Date:
Reason for the visit:
Which hospital / crisis centre?
Were you hospitalised?
If so, how long were you hospitalised for?
Visit 3:
Date:
Reason for the visit:
Which hospital / crisis centre?
Were you hospitalised?
If so, how long were you hospitalised for?
Have you thought seriously about ending your life? [Y/N]
If so, you began thinking this way starting at age ______
How many times have you tried to end your life? ______
For the three most significant suicide attempts you have had, that is, those which have had
the most consequences on your life, please write, as best as you can remember:
Suicide attempt 1
Date:
Reason for the suicide attempt:
Method used:
Required medical attention? [Y/N]
Any physical consequences:
Suicide attempt 2
Date:
Reason for the suicide attempt:
Method used:
Required medical attention? [Y/N]
Any physical consequences:
Suicide attempt 3
Date:
Reason for the suicide attempt:
Method used:
Required medical attention? [Y/N]
Any physical consequences:
If the above three attempts do not include your most recent suicide attempt, please tell us
about your most recent suicide attempt:
Most recent suicide attempt
Date:
Reason for the suicide attempt:
Method used:
Required medical attention? [Y/N]
Any physical consequences:
For the last three doctor that you have seen for mental health issues, such as psychiatrist or
family doctor, whether in a significant hospitalisation or in a clinic, please write, as best as
you can remember in chronological order:
MD number 1
Date of first visit:
Type of professional:
Name of professional:
How many times you saw the professional:
Date of last visit:
Reason you saw the professional:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Diagnoses given:
Treatments tried:
Was the treatment helpful? Why or why not?
MD number 2
Date of first visit:
Type of professional:
Name of professional:
How many times you saw the professional:
Date of last visit:
Reason you saw the professional:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Diagnoses given:
Treatments tried:
Was the treatment helpful? Why or why not?
MD number 3
Date of first visit:
Type of professional:
Name of professional:
How many times you saw the professional:
Date of last visit:
Reason you saw the professional:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Diagnoses given:
Treatments tried:
Was the treatment helpful? Why or why not?
Have you ever seen a neuropsychologist or undergood neuropsychological testing (for
example, for ADHD or Autism Spectrum Disorder?) [Y/N]
If yes, when? ______
What was the result? ______
For the last five medications have you taken in the past for your mental health, please write:
Medication 1
Medication name:
Maximum dose:
Your age when you began the medication:
How long you took it for:
Was the medication helpful, and if so, how?
_________________________________________________________________________
_________________________________________________________________________
Any side effects?
Why did you stop?
Medication 2
Medication name:
Maximum dose:
Your age when you began the medication:
How long you took it for:
Was the medication helpful, and if so, how?
_________________________________________________________________________
_________________________________________________________________________
Any side effects?
Why did you stop?
Medication 3
Medication name:
Maximum dose:
Your age when you began the medication:
How long you took it for:
Was the medication helpful, and if so, how?
_________________________________________________________________________
_________________________________________________________________________
Any side effects?
Why did you stop?
Medication 4
Medication name:
Maximum dose:
Your age when you began the medication:
How long you took it for:
Was the medication helpful, and if so, how?
_________________________________________________________________________
_________________________________________________________________________
Any side effects?
Why did you stop?
Medication 5
Medication name:
Maximum dose:
Your age when you began the medication:
How long you took it for:
Was the medication helpful, and if so, how?
_________________________________________________________________________
_________________________________________________________________________
Any side effects?
Why did you stop?
If you have had psychotherapy (talk therapy before), please tell us for your last three
therapists:
Therapist 1
Therapist name:
Number of sessions you had with this person:
Start date:
End date:
Type of therapy (e.g. CBT, psychodynamic):
Was it helpful, and if so, how?
_________________________________________________________________________
_________________________________________________________________________
Anything you did not like about the therapy?
_________________________________________________________________________
_________________________________________________________________________
Why did you stop?
Therapist 2
Therapist name:
Number of sessions you had with this person:
Start date:
End date:
Type of therapy (e.g. CBT, psychodynamic):
Was it helpful, and if so, how?
_________________________________________________________________________
_________________________________________________________________________
Anything you did not like about the therapy?
_________________________________________________________________________
_________________________________________________________________________
Why did you stop?
Therapist 3
Therapist name:
Number of sessions you had with this person:
Start date:
End date:
Type of therapy (e.g. CBT, psychodynamic):
Was it helpful, and if so, how?
_________________________________________________________________________
_________________________________________________________________________
Anything you did not like about the therapy?
_________________________________________________________________________
_________________________________________________________________________
Why did you stop?
Medical history
Please list all your current physical health problems
Diagnosis Your age at diagnosis Current treatment
1. _______ _______ _________________
2. _______ _______ _________________
3. _______ _______ _________________
4. _______ _______ _________________
5. _______ _______ _________________
6. _______ _______ _________________
7. _______ _______ _________________
Please list all your significant past physical health problems
Diagnosis Surgery or When was the surgery
hospitalisation or hospitalisation?
1. _______ _______ _________________
2. _______ _______ _________________
3. _______ _______ _________________
4. _______ _______ _________________
5. _______ _______ _________________
6. _______ _______ _________________
7. _______ _______ _________________
Have you ever had a concussion? [Y/N]
Have you ever had a seizure? [Y/N]
Have you ever fainted? [Y/N]
Family history
Is anyone related to you genetically (by blood) known for:
Who is it? (Relation to you) Was it diagnosed? Hospitalised?
Depression ___________ ___________ __________
Anxiety disorder ___________ ___________ __________
OCD ___________ ___________ __________
Schizophrenia ___________ ___________ __________
Bipolar disorder ___________ ___________ __________
ADHD ___________ ___________ __________
Personality disorder ___________ ___________ __________
Alcohol addiction ___________ ___________ __________
Eating disorder ___________ ___________ __________
Other addiction ___________ ___________ __________
Other mental health disorder(s) in people related to your genetically:
_________________________________________________________________________
_________________________________________________________________________
Has anyone in your family attempted suicide? [Y/N]
If yes, who? ______
To the best of your knowledge, how many times has this person tried? _____
Has anyone in your family succeeded in suicide? [Y/N]
If yes, who? ______
When did it happen? ______
Is anyone related to you genetically (by blood) diagnosed with dementia? [Y/N]
If so, who? ____
Is anyone related to you genetically (by blood) diagnosed with heart disease? [Y/N]
If so, who? ____
Substance use history
Alcohol
1. Please write all the forms you drink regularly (beer, wine, spirits, etc.)
____________________________________________________
2. How many times a week do you drink? ____________________
3. On average, how many drinks each time? ___________________
4. In the last five years, what is the maximum number of drinks you’ve had in a single
sitting? ________
5. In your life, what is the maximum number of drinks you’ve had in a single sitting?
_______
Cigarettes
1. Please write all the forms you use regularly (cigarettes, cigars, vaping, etc.)
____________________________________________________
2. How many cigarettes (or cigars, or grams of nicotine) a day?
______________________
Marijuana
1. Please write all the forms you use regularly (joints, blunts, edibles, vaping, etc.)
____________________________________________________
2. How often do you take marijuana per week? _____
3. How many grams of marijuana each time? ____
Cocaine
1. Please write all the types and routes you use (crack, cocaine, IV, snorted, etc.)
____________________________________________________
2. How many times per week or month? ___________
3. About how many grams each time? ___________
Opiates
1. Please write all the types and routes you use (morphine, heroin, dilaudid, fentanyl, IV,
oral, smoked, etc.)
____________________________________________________
2. How many times per week or month? ___________
3. About how many grams each time? ___________
Stimulants (including MDMA)
1. Please write all the types and routes you use (Speed, crystal meth, IV, oral, smoked,
etc.)
____________________________________________________
2. How many times per week or month? ___________
3. About how much each time? ___________
Hallucinogens
1. Please write all the types you use (MDMA, LSD, magic mushrooms, ketamine, etc.)
____________________________________________________
2. How many times per week or month? ___________
3. About how much each time? ___________
Caffeine
1. Please write all the forms you use regularly (coffee, energy drinks, caffeine pills, etc.):
____________________________________________________
2. How many times per day do you have caffeine intake? ________________
3. About how much each time? ___________
Others
1. Please let us know of any substances you use regularly _____
2. How many times per week or month?
3. About how much each time?
Has substance use ever caused strains in your relationships with other people, or at work? If
so, how bad was it?
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Have you ever tried cutting down on a substance? If so, please indicate which and what help
you may have received (e.g. Alcohol Anonymous, Fosters, Homewood, etc.)
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Legal history
Have you ever been in front of a judge? If so, what happened and what was the outcome?
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Habits and lifestyle
Is sleep a problem for you? [Y/N]
If yes, please fill out the following section:
Since when has sleep been a problem for you? _____
Which part of sleep do you have trouble with? (Check all that applies)
1. Cannot fall asleep
2. Cannot stay asleep
3. Wake up too early in the morning
4. Wake up frequently at night
5. Wake up in a panic
6. Nightmares or dreams
7. Other _______________
Currently, how many hours do you sleep in a 24 hour cycle? _____
Currently, do you nap during the day? [Y/N]
- How many naps do you take during the day? ______
- Over average, how many hours do you nap in one day? _____
Approximately when do you fall asleep at night? ______
Approximately when do you wake up in the morning on weekdays? ______
Approximately when do you wake up on weekends? ______
Is eating, food intake or diet a problem for you? [Y/N]
If yes, please fill out the following section:
Since when has eating been a problem for you? _____
In what way is eating a problem for you? (Check all that applies)
1. I eat too much food
2. I eat too little food
3. I eat very irregularly
4. I eat in large binges
5. I will only eat very few foods
6. I don’t like the texture or taste of most foods
7. Other ______
Your diet has significant amounts of: (check all that applies)
1. Unprocessed carbohydrates (bread, pasta, rice, etc.)
2. Processed carbohydrates (chips, cookies, ice cream, etc.)
3. Red meats
4. White meats
5. Non-meat, non-dairy proteins (soy, tofu, lentils)
6. Dairy products
7. Fruits and vegetables
8. Other _____
Do you enjoy your meals?
1. Yes
2. No
3. Sometimes
4. Not sure
How many meals do you have a day? _____
Is your lifestyle:
1. Sedentary (sitting or lying down most of the day)
2. Moderate (walking or other movement more than an hour a day)
3. Active (running or physical labour more than an hour a day)?
How much time do you do moderate exercise (heart rate > 100 beats per minute) per week?
1. <30 min
2. 30 min - 1 hour
3. 1-2 hours
4. 2-4 hours
5. >4 hours
How much time do you do vigorous exercise (heart rate > 150 beats per minute) per week?
1. <15 minutes
2. 15-30 minutes
3. 30 min - 1 hour
4. 1-2 hours
5. >2 hours
Do you enjoy exercise?
How much time do you spend in leisure activities (activities undertaken purely for pleasure) a
week?
1. <1 hour
2. 1-2 hours
3. 2-4 hours
4. 4-8 hours
5. > 8 hours
Do you enjoy leisure? [Y/N]
How much time do you spend in social activities (spending time with other people purely for
their company) a week?
1. <1 hour
2. 1-2 hours
3. 2-4 hours
4. 4-8 hours
5. > 8 hours
Do you enjoy socialising? [Y/N]
Do your days consist of regular, structured activities?
1. Yes, I follow a schedule or routine on most days
2. Sometimes. I follow a schedule for certain portions of the day (e.g. at work) but not
other portions (e.g. at home)
3. Sometimes. I follow a schedule for certain days and no schedule for other days.
4. My days have no consistent structure or routine
5. My days have no activity, and thus no schedule
6. Other: ____________________
Major stressors
Please check all that apply:
1. Occupational -- problems with work
2. Financial -- not enough money
3. Housing -- cannot find adequate housing
4. Medical -- I have health problems
5. Caregiving -- I have to take care of other people
6. Education -- problems with school
7. Relational -- conflicts or other issues with another person or people in your life
8. Legal -- I am undergoing a court case or I broke the law
9. Immigration -- issues related to coming to another country
10.Other: ______________________________
