Pre-Screening Questionnaire-Adult Name(Required) First Last Email(Required) Past medical history:Surgical historyDevelopmental delayFamily history: (Any family members experiencing mental issues)Psychiatric diagnosis: Anxiety Depression OCD Bipolar Disorder PTSD ADHD Any psychiatric hospital admission?In patient treatment:Out patient treatment:Drug/Alcohol rehab:Alcohol abuse:Drug abuse:Do you use any illicit or recreational drugs?Are you smoking cigarette? If yes, how many sticks per day?.Are you smoking marijuana? If yes, how many grams per day?.What is your highest educational attainment?Do you feel anxious or depressed for the past couple of months, weeks or days?Are you having trouble focusing and concentrating?Are you having issues in sleeping?Active medication:Current job:Living situation:Allergies:Height and weight:
