Initial Consult Form Name First Name Last Name In last 2 weeks, how often have you felt little interest or pleasure in doing things? * Not at all Several days a week More than half the days Nearly every day Over last 2 weeks, how often have you felt down, depressed or hopeless? * Not at all Several days a week More than half the days a week Nearly every day Over the last 2 weeks, how often have you had trouble falling or staying asleep, or sleeping too much? * Not at all Several days a week More than half the days Nearly every day Over the last 2 weeks, how often have you felt tired or having little energy? * Not at all Several days a week More than half the days Nearly every day Over the last 2 weeks, how often have you had poor appetite or overeating? * Not at all Several days a week More than half the days Nearly every day Over the last 2 weeks, how often have you felt bad about yourself- or thought that you are a failure or have let yourself or your family down? * Not at all Several days a week More than half the days Nearly every day Over the last 2 weeks, how often have you had trouble concentrating on things, such as reading the newspaper or watching television? Not at all Several days a week More than half the days Nearly every day Over the last 2 weeks, how often have you noticed moving or speaking so slowly that other people could have noticed? Or so fidgety or restless that you have been moving a lot more than usual? * Not at all Several days a week More than half the days Nearly every day Over the last 2 weeks, how often have you thought that you would be better off dead, or thoughts of hurting yourself in some way * Not at all Several days a week More than half the days Nearly every day Line Over the last 2 weeks, how often have you felt nervous, anxious or on edge? * Not at all Several days Over half the days Nearly every day Over the last 2 weeks, how often have you not being able to stop or control worrying * Not at all Several days Over half the days Nearly every day Over the last 2 weeks, how often have you found yourself worrying too much about different things * Not at all Several days Over half the days Nearly every day Over the last 2 weeks, how often have you had trouble relaxing * Not at all Several days Over half the days Nearly every day Over the last 2 weeks, how often have you been so restless that it's hard to sit still * Not at all Several days Over half the days Nearly every day Over the last 2 weeks, how often have you found yourself becoming easily annoyed or irritable * Not at all Several days Over half the days Nearly every day Over the last 2 weeks, how often have you felt afraid as if something awful might happen * Not at all Several days Over half the days Nearly every day Line I do structured exercise * structured means setting aside time for exercise either at home, outside or at a gym rarely some walking most days nearly every day My eating pattern is * Omnivore (both animal and plant-foods) Pescetarian (only fish for meat, no chicken, beef, pork, etc) Vegetarian (no meat) Vegan (no animal products) Paleo Ketogenic Carnivore Other I eat chips, chocolate bars, ice cream, cookies, etc * most days 1 - 3 times a week rarely or never I drink alcohol * socially several times a week most days never Cups of coffee or caffeinated tea * daily several times a week rare/never I get 20 - 30 mins of sun exposure daily * yes no I watch TV, Netflix, Youtube * rarely 1 hr /d 2 - 3 hrs/d 3 + hrs/d My social media use is * Facebook, instagram, twitter, snapchat, etc less than 1 hr/d 1 - 2 hrs/d 3 + hrs/d Pornography use rare / never several times a week most days a week several times a day Music preferences Marital status * single single (divorced / separated) married I have marital or family stress? * rarely sometimes often Do you have a friends or family members you can confide in? * yes no Cigarettes, vaping or recreational drugs? * yes no Gambling * yes no Sources of stress (if applicable) I have financial stressors * yes no sometimes My occupation * Do you have any spiritual practices? (prayer, meditation, devotional reading, journaling?) I'd appreciate prayer at the end of the consult? Yes No Pray for me privately but not at consult Anything else you would like to share with Dr Cho ahead of your visit? Thank you for filling out the initial intake form! Dr Cho looks forward to connecting with you at your initial consult