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Loretta Butehorn, Ph.D., CCH Associates
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Loretta Butehorn,Ph.D., CCH 345Neponset Avenue Boston,Massachusetts 02122 1-617-529-2806 www.lorettabutehornphd.com
NAME:_________________ DOB:_________Today’s date: _______ Referred by:_______________________ Referral phone:_________ Your Phone:_____________Email:____________________ Address: ______________________________________________
Please call to make appointment as soon as you receive intake form as there is often a waiting list. Thank you Everything on this questionnaire is completely confidential. If there are any questions you do not
feel comfortable answering , you may leave blank.
1. What bothers you most these days (chief complaint CC)_________ 2. At what time of the day or night is the CC the worst? Specify an hour if you can _____________________. 3. When did this begin _________? 4. What was going on in your life when this first started___________ _______________________________? 5. What important life events took place in six months prior to problem starting ___________________________________________? 6. What makes you feel better (types of food, weather heat/cold light/noise, anything else you can think of)_______________________________________? 7. What is biggest stress in your life right now ____________________ ? How do you like to deal with what upsets you: circle all which apply: Talk Be left alone Not Think About It Take Action Other_____ 8. What do you worry about _____________________? 9. What is the "craziest” worry have __________________? 10. Give a numerical rating for each personality trait 0- 10 (with 10 greatest amount.) a. self confidence__ b. self critical___ c. jealous___ d. neat___ e. anxious, worrisome___ f. fearful____ g. down in dumps___ h. critical of others___ i. easy going_ j. tearful___ k. stoic (strong silent type)___ l. talkative____ m. quiet___ n. shy___ o. outgoing____ p. spiritual____ q. clairvoyant____ r. sensuous____ s. enjoys eating___ t. bored___ u. tired____ v. hopeless___ w. angry____ x. energetic____ y.
like to be helpful___ 10. What medications do you take more than 1x per month _____? What recreational drugs do you use daily _______ monthly ________ occasionally ________? 11. How many alcohol drinks do you take a day _______? Have you ever had detox for alcohol or drug use?____________ Have you ever had an alcohol/drug evaluation?________If so, when________. 12. Do you smoke?________Ever?__________Date stopped?___________Multiple starts and stops please note on back sheet. 13. How well do you sleep (1-10 10 =excellent) _________? What do you dream
about _______? Do you remember your dreams? _____ What are they about?_____________________________ Do you have recurring
dreams?____ About what____________________________________________________________________________________________________When
you awake how do you generally feel?(refreshed-groggy-tired-etc)__________ Do you typically wake up in the middle
of the night at a particular time?________What time ?________What’s on your mind ?___________What do you do to go back
to sleep? __________How long does it take ?__________ 14. Mention anything else about your physical-mental-emotional state that you are aware of_______________________________________________ 15. What other symptoms accompany your CC?________________________________________ 16. What aches-pains-irritations do you have which you might think
“are not worth mentioning?”____________________________________________ 17. What are your fears in life? _________ Any other fears (darkness, being alone, in crowds, altitude, flying, elevators, etc.)?___________________________ What are you most fearful of (real or irrational)_______? 18. Do you weep easily ______? About what kinds of things_________________________? 19. How do other people view you? ________________________ What do others complain about in you?_____________ 20. How do you react to stress?____________________________ What is the biggest stress factor in your life now?___________________ 21. Are you a tidy person or not so tidy?______ Do you tend to collect things?_____________Do you like to be on time___________Are you usually early/late________________Why_______________ 22. What bothers you most in other people? ______ How do you react to it?____________________ 23. What do you do for work? _______Are you happy in your work?________ Ideally, what would you like to do?____________ What hobbies, interests or activities do you engage in regularly ?____________________Are there any you keep thinking you’d like to “take up?”________________ 24. If you had an unexpected week's paid vacation from work, what would you do? _____________________________________________________ 25. On what occasions do you feel jealous? _________________ 26. Are you clairvoyant? _____________________Psychic? ____________ 27. Do you think of yourself as a religious person? ____ A spiritual person? ____Say more about this, please________________________________________________________________________________________________. 28. What do you do for fun? ________________________________ 29. What types of movies do you most enjoy? __________TV programs? _________Books?_________ 30. How many hours a day do you spend at a computer?______On Internet?_________What type of Internet sites most intrique?_________Give you most enjoyment?__________ 31. If you were going
to a costume ball and had to dress up like a real or fictional character MOST reflective of you, which character might that
be? __________________ 32. Have you been in counseling before?__________Dates________Issues____________When did you end treatment__________Why__________Did you terminate with therapist_______________.Please list all dates and issues on back of this sheet for multiple treatments. 33. Where you ever on any medication for emotional/psychological issues?___________Where they helpful?___________What was/wasnot helpful___________________________________When did you last take these medications?__________________________ 34. Have
you ever been psychiatrically hospitalized?_________ Was this helpful?_________Why/why not?_____________ 35. What medications are you taking at present?_________________________ 36. Any TB or any gonorrhea, syphilis or other sexually transmitted diseases in your history or that of your parents, grandparents, great-grandparents, etc.? _______________________ 37. Family History: Mention diseases and causes and age of death of parents and siblings. ________________________________________________________________________. 38. Time Line: A. Mention from birth on to the present day all important traumas, both emotional and physical, heartbreaks, divorces, work-related events, surgeries and other physical traumas, diseases or traumas your mother had while pregnant with you, family stress, death of family members or friends, disappointments, etc. Also mention positive events such as marriage, birth of children, etc. (Write at end of form for timeline.) B.
On timeline indicate dates (approximate) of treatment for any
physical or mental/emotional problems (i.e. measles, heart attack, manic depressive episode, outpatient therapy for anxiety,
steroids for allergies etc.) 39. How you feel after meals?_____________How do you feel if you go without a meal?_______________ Food: cravings for:_________________________Aversions to (dislike taste,bad reactions to ) _________________________________Describe your diet in a few words:______________________________________________If you could eat without any health consequences what would you diet be like?_________ Why is that__________________What are your favorite foods__________?. What food do you dislike____________? Are you thirsty__________ For hot drinks______cold drinks_________ice cubes_________Do you drink with big gulps or little sips throughout the day________ Favorite drink_____________ Do you drink coffee?__________If yes,how many cups per day__________. 40. Gastrointestinal symptoms after meals: gas____indigestion_____burping_____bloating?_______Location: above the navel?___below the navel?_____ both?____Bowel movement: Frequency if you don't use a laxative:_______Frequency of use of laxative_____________.Any problems with urination or bowel movements__________________________________________________________________ PERSONAL RESPONSE TO ENVIRONMENT 41. What sort of weather do you dislike most? (damp, cool, hot, windy, etc.) Are you a chilly or a hot person?__________ Or is it difficult for you to find a comfortable temperature?______________________ 42. Are you generally cold or warm? (circle one) When are you too hot or too cold ?____________ 43. How do you react towards sunlight?_________________Do you wear sunglasses a lot?___________________ 44. Do you have dry or oily skin? _______________ Is the skin on your face different from the rest of your body?__________Do you have brittle nails?______________ 45. Have you had any of the following?. Warts: where year treatment Cysts: where year treatment Polyps: where year treatment Tumors: where year treatment Skin disorders: where year treatment 46. Do you perspire a great deal?____When and where on body? (feet, head, hair, armpits, etc.)___________________________________ 47. Allergies?_______________When____________Symptoms__________Since
what age________ 48. Menses: age first began________ time between periods, in days._________ duration_______color/clots________________PMS symptoms__________ 49. No. of pregnancies:_____ no. of children________miscarriages________abortions___ 50. Discharges: post-nasal drip?________vaginal?_________other?________ Color, consistency, time of these discharges_______________________
51. Do you tend to need a smaller doses of medicines than most people? ___________Do you need less anesthesia than most people?________Do you have a hard time coming out of anesthesia?_________Do you tend to react to vitamins and herbs and/or need hypoallergenic vitamins?______________ 52. Have you had any vaccinations since the standard childhood ones?__Have you ever had any adverse reactions to vaccinations?_________________________ 53. When was your last physical________Any problems then___________________________Treatments given at that time______________________________________________? 54. What pain do you experience on any kind of regular basis____________________? Where do you feel pain:left side________right side______both sides________other description__________. What type of pain is it: burning_______stabbing______aching_____pressure________other________. How frequently do you have pain (be as specific as possible) AM_____PM_____Upon waking_____Daily_____Monthly______Every _________? What makes pain better (other than medication, i.e. moving about, eating, etc)_____________What makes pain worse_____________________ Frequency of pain in the month___________.
55. How would someone who knows you well describe you__________________________________________________________________________________________________________________________________________________________ 56. How would a causal acquaintance describe you _________________________________________________________________________ 57. How would you describe yourself________________________________________________________________________________________________________________________ 58. What treatment are you currently using for your CC ______________________________________________________________________________________________________________________________ 59. Please do not stop any current treatment until homeopathic treatment has begun to help and you have talked to your allopathic physician. 60. What else would you like to tell me about yourself or your condition that has not been covered in this questionnaire?__________________________________________________________________________________
1. Quality of life ______ 2. Energy to live my life ___ 3. Enjoyment I get out of life______ 4. Quality of my intimate relationships____ 5. Quality of my friendships_____ 6. Quality of my familial relationships_____ 7. General sense of well being_____ 8. Belief my health problems are resolvable______
What does this problem stop you from doing?_______________________Requires that you do____________________________________________.
Why is this problematic_______________________________________________________________.
If possible, Please mail or e-mail
this in ahead of appointment: |
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