 BriZ
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| Joined: 12 Jul 2005 |
| Total Posts: 1 |
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Add additional questions
Posted: 12 Jul 2005 01:54 PM |
Listed below are some questions on our intake form that we would like to include in the database for our clients. This is for the sake of providing us with a more complete picture of the client's past experiences, current circumstances, and requests for assistance.
INITIAL INTAKE FORM:
1. Occupation/Job _____________________________
2. How do you feel about this possible pregnancy? (Please check any and all that apply)
Scared Nervous Excited Undecided In Denial Upset Frightened Angry Happy Uncertain
3. I would like help and/or information regarding: (Please check any and all that apply)
Parenting, Adoption, Abortion, Sexually transmitted diseases, Relationships, How to wait to have sex
PREGNANCY TEST FORM:
1. At what age did your menstrual cycle (period) begin? _________
2. Under Medical History
Previous Pregnancies: Yes No If yes, when? __________________
Miscarried/tubal stillborn Yes No If yes, when? __________________
Previous Abortion Yes No If yes, when? __________________
Have you experienced any of the following symptoms?
Grief and Sadness Yes No If yes, how often? _______________
Intense Anger or Rage Yes No If yes, how often? _______________
Suicidal Thoughts Yes No If yes, how often? _______________
Difficulty Keeping Close Relationships Yes No If yes, how often? _______________
Increased alcohol/drug use Yes No If yes, how often? _______________
3. On _____________(date), I performed a pregnancy test at Pregnancy Services of Gratiot County that was provided by this office.
I collected my urine while at PSGC.
I was provided a step by step clarification of the manufacturer’s instructions.
I did not receive assistance in the actual administration of the pregnancy test.
I interpreted the test results as:
Positive Negative Inconclusive
I give Pregnancy Services permission to contact me: Yes No
If yes, is it okay to say who we are when we call you?
Yes No Does not matter
If yes, do you wish for all mail correspondence to be sent in an unmarked envelope?
Yes No Does not matter
Please use the following information to contact me:
_________________________________________________
_________________________________________________
I have read and understand the above statements and questions __________________________________
(Signature)
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Re: Add additional questions
Posted: 14 Jul 2005 09:00 AM |
Hi BriZ,
Thanks for your detailed feedback. We are currently in the middle of getting out a a fairly significant release of CenterPiece. If there are any of your requests above that we can slip in to this release, i'll let you know. We may have some follow-on questions for you. I'll keep you posted once we have more time to evaluate your requests. Thanks! |
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