PATIENT INTAKE / HISTORY FORM PATIENT INFORMATION

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PATIENT INTAKE / HISTORY FORM PATIENT INFORMATION

Name: _____________________________________ DOB:_________

Address: _____________________________________________________

City/State: ____________________________ Zip Code: _________

Home phone: Work phone:

Cell phone: Email:

DESCRIBE YOUR RELATIONSHIP TO THE PATIENT

□ Self □ Parent □ Family □ Spouse □ Brother/Sister □ Friend

□ Other/ Practitioner □ Legal Guardian □ Other:

MEDICAL PROBLEMS Pain

□ headaches □ joint pain □ abnormal muscle contractions □ pain during menses

□ pain during urination □ back pain □ chest pain □ stomach pain

□ rectum pain □ arm/leg pain □ pain during sex

□ OTHER:

Gastro-intestinal problems

□ bloating □ nausea □ diarrhea □ food intolerance □ IBS

□ vomiting (not during pregnancy) □ constipation □ OTHER:

Sexual problems

□ irregular period □ inability to orgasm □ lack of interest in sex

□ erectile dysfunction □ excessive menstrual bleeding

□ OTHER:

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MEDICAL PROBLEMS (Continued):

Neurological problems

□ poor vision □ double vision □ poor hearing □ ringing in the ears

□ coordination problems □ muscle weakness □ tremor

□ urinary retention □ difficulty swallowing □ seizures □ paralysis □ dizziness

□ speech problems □ stroke □ aneurysm □ brain tumor □ numbness to touch

□ problems walking □ doctors can't find what's wrong □ Parkinson’s □ MS

□ traumatic brain injury (TBI) □ stroke □ learning disorder

□ Allergies?_______________________________________________________

□ Other Medical Problems? (Please describe)

MENTAL / EMOTIONAL PROBLEMS

□ anxiety □ depression □ sadness □ difficulty focusing □ irrational fears

□ no motivation □ slowed thinking □ easily angered □ panic attacks

□ difficulty paying attention □ sleep problems □ hate crowds □ can’t leave house

□ can’t make change □ crying □ difficulty making decisions

□ cutting/other self harm □ over eating/emotional eating □ reduced interest in sex

□ drug abuse □ seeing things □ suicidal thoughts □ hearing voices

□ phobias □ suspicious □ OTHER:

HOW DO YOUR PROBLEMS AFFECT YOUR LIFE?

□ I have lots of arguments □ I can’t work □ I avoid people

□ I don’t want to leave the house □ I can’t keep relationships

□ I have been fired from jobs □ I wake up several times a night

□ I can’t fall asleep □ I am concerned with my weight

□ I never feel rested □ I wake up too early and can’t fall back asleep

□ I can’t stay organized □ I can’t take care of myself anymore

□ It makes me upset to think how I can't do the things I used to do

□ I can’t stop worrying □ Pain all the time makes it difficult to do anything

□ OTHER:

FAMILY HISTORY

Where were you born? _______________________________________

Where did you grow up?_______________________________________

What was your childhood like?

Were you ever abused as a child?

□ Physically? □ Sexually? □ Verbally?

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Anyone in your family (relatives or ancestors) ever have any mental or emotional problems? □ Yes □ No

Anyone in your family (relatives or ancestors) ever have any drug / alcohol problems?

□ Yes □ No

EDUCATION

How far did you go in school? __________________

What was your highest grade completed? ________

Did you earn a GED? □ Yes □ No

Did you ever attend a vocational school/ program? □ Yes □ No Were you ever assessed for a learning problem? □ Yes □ No How would you describe yourself as a student?

MARITAL STATUS / LIVING SITUATION

□ single □ partnered □ married □ common-law marriage

□ widow □ live with significant other □ divorced □ separated

How long divorced? _____

How long have you been married/partnered? _____

Number of times married in your life? _____

Number of children you had, in your life? _____

How many years was your longest relationship? _____

Number of adults in the house? ________

□ single-family house □ apartment □ duplex □ trailer □ condo Any minors in the house? □ Yes □ No

Names and ages?

Pets? __________

MILITARY □ NONE

□ Army □ Navy □ Marines □ Air Force □ Coast Guard □ Nat. Guard How long did you serve?

Were you ever deployed? □ yes □ no How were you discharged?

What rank did you leave as?

What was your job/duty?

LEGAL

Ever had a lawsuit? □ yes □ no Do you have an attorney now? □ yes □ no

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PREVIOUS EMPLOYMENT (Attach resume if desired)