Health History Questionnaire page 4
Before filling out any questionnaires, please print and sign the forms under the Patient Forms tab at Bring them to your next appointment with Dr. Alise Jones-Bailey. Thank you.
Patient Name: *
Your answer
Date of Birth *
Poor memory
Lack of motivation
Sleep problems
Nervous tics of habits
Frustration with self
Frustration with others
Lack of sense of humor
Inability to make decisions
LIFESTYLE ASSESSMENT: Cigarettes/How long?
Your answer
Pipe/How long?
Your answer
Your answer
Average number of alcoholic drinks per week:
Your answer
The average number of social or business meals eaten out per week:
Your answer
Number of overnight business trips per month:
Your answer
Job title or responsibility:
Your answer
For you typically take work home?
Your answer
JOB/WORKPLACE ASSESSMENT: The consequences are severe if I make a mistake at work.
I frequently experience personal conflicts and/or harassment at work
My job requires dealing with lots of red tape and frustration to get things done.
I can talk openly with management and my co-workers.
My company supports my efforts and rewards my contributions.
I feel I deserve more compensation.
I feel my job is at a dead end.
My company has reasonable policies for sick time, vacation, health and other benefits.
I am allowed a great deal of flexibility in my work schedule.
I experience a great deal of change and uncertainty in my job.
Other job/workplace comments:
Your answer
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