Tranquility Behavioral Health Patient Portal

Tranquility Behavioral Health Abnormal Movement Questionnaire

Patient First & Last Name * D.O.B. *

Are you having any body movements you can't control? Have others noticed or commented on particular movements? Please select a description of the movements from the options below.

HEAD/ FACE

If OTHER was selected, please describe

UPPER LIMBS

If OTHER was selected, please describe

TORSO

If OTHER was selected, please describe

LOWER LIMBS

If OTHER was selected, please describe

ASSESS IMPACT

Have these movements impacted your daily routine? For example, while you are doing things like eating, walking, talking, or typing?o How have these movements bothered you? Do you experience embarrassment or isolation because of them? IF YES, PLEASE DESCRIBE

If YES, please describe

THINK

When you first noticed these movements, what did you think of them? * Have other people noticed your movements? What do you think they think is happening? *

FEEL

How do the movements make you feel? *

ACT

How do the movements make you act? * Have these movements impacted your daily routine? lf so, how? * Patient/Guardian Initials * Date Completed *