Health History Questionnaire page 4
Before filling out any questionnaires, please print and sign the forms under the Patient Forms tab at http://www.drjonesbailey.com. Bring them to your next appointment with Dr. Alise Jones-Bailey. Thank you.
Patient Name: *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
YOUR EMOTIONAL STATE: Depression
Poor memory
Boredom
Lack of motivation
Sleep problems
Nervous tics of habits
Anger
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
Overweight?
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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