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CPM Intake Questionnaire
Name of Client:
Sex: Male Female
Date of Accident:

 

Please select the degree of change in your life in the following areas, due to the subject motor vehicle accident.
 
1. Changes in your sleep pattern – difficulty falling asleep, staying asleep, early morning awakenings or nightmares.
No Change Mild Moderate Severe
2. Average hours of nightly sleep before accident after accident
3. Change in your appetite, either significant increase or decrease.
No Change Mild Moderate Severe
4. Changes in memory or concentration.
No Change Mild Moderate Severe
5. Changes in your mood.
      A. More Depressed
No Change Mild Moderate Severe
      B. More angry and irritable
No Change Mild Moderate Severe
6. Changes in your relationships – tension or withdrawal from loved ones or friends.
No Change Mild Moderate Severe
7. Changes in your anxiety level when travelling in a motor vehicle. 
No Change Mild Moderate Severe
 
I understand that the information I provided will be used by Dr. Steiner to determine the need for a psychological evaluation regarding chronic pain related depression and anxiety. I consent to share this information with my insurance company and understand that the cost of this evaluation will be paid for by my accident benefits.


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