PSYCHIATRY
Patient Name: Date: / /
Date of Birth: / / Age:
Pharmacy Name: _______________________ Pharmacy Phone #: __________________ Primary Care Physician: Current Therapist/Counselor: How did you hear about us?
☐ Internet ☐ Insurance
☐ Family member ☐ Friend ☐ Therapist ☐ PCP ☐ Other Other Providers (specialty):
What are the problem(s) you are seeking help for? Date of Onset 1.
2. 3.
Why are you seeking help now?
What are the major stressors in your life? (relations, work, academic, financial, medical, legal, etc)
Current Psychiatric Symptoms Checklist: (check symptoms below for last 2 weeks) ☐ Depressed mood
☐ Unable to enjoy activities ☐ Increased irritability ☐ Loss of interest ☐ Crying spells ☐ Excessive guilt ☐ Hopelessness ☐ Decreased libido ☐ Racing thoughts ☐ Impulsivity
☐ Decreased need for sleep ☐ Excessive energy
☐ Increase risky behavior ☐ Anger outbursts
☐ Increased libido
☐ Excessive worry ☐ Anxiety attacks ☐ Avoidance
☐ Repetitive unwanted (“intrusive”) thoughts
☐ Binge eating or purging ☐ Fear of being left alone
(abandoned) ☐ Sleep pattern disturbance (________ hrs/d)
☐ Change in appetite
☐ Fatigue
☐ Concentration/forgetfulness
☐ Hallucinations ☐ Suspiciousness
PSYCHIATRY
REVIEW OF SYSTEMS
Please, check if you had experienced any of the symptoms below, this past week
General: ☐ Fever ☐ Chills ☐ Night Sweats ☐ Weight Change Skin: ☐ Rash ☐ Itching ☐ Easily Bruising ☐ Hair Loss Neck: ☐ Neck Pain ☐ Neck Stiffness ☐ Neck Swelling HEENT: ☐ Dry Mouth ☐ Bleeding Gums ☐ Snoring ☐ Blurred Vision ☐ Hearing Loss ☐ Ringing In Ear ☐ Nose Bleeding Respiratory: ☐ Cough ☐ Snoring ☐ Difficulty Breathing Cardiovascular: ☐ Palpitations ☐ Chest Pain ☐ Leg Swelling
☐ Irregular Heart Beat Gastrointestinal: ☐ Nausea ☐ Vomiting ☐ Diarrhea ☐ Constipation ☐ Stomach Ache ☐ Bloating ☐ Bloody Stool Musculoskeletal: ☐ Joint Stiffness ☐ Joint Swelling ☐ Back Pain ☐ Muscle Weakness Neurological: ☐ Headaches ☐ Tremors ☐ Dizzy ☐ Lightheaded ☐ Fainting ☐ Numbness
PAST PSYCHIATRIC HISTORY
Have you ever received any outpatient psychiatric treatment? (meds, psychotherapy, CBT, EMDR, TMS, other)
Reason Dates Treated By Whom How treated?
Have you ever received any inpatient (hospital) psychiatric treatment?
Reason Dates Hospitalized Where?
PSYCHIATRY
Check if you have ever taken any of the following medications: Antidepressants ☐ Prozac (fluoxetine) ☐ Zoloft (sertraline) ☐ Luvox (fluvoxamine) ☐ Paxil (paroxetine) ☐ Celexa (citalopram) ☐ Lexapro (escitalopram) ☐ Viibryd (Vilazodone) ☐ Brintellix (vortioxetine) ☐ Effexor (venlafaxine) ☐ Cymbalta (duloxetine) ☐ Pristiq (desvenlafaxine) ☐ Fetzima (levomilnacipran) ☐ Wellbutrin (bupropion) ☐ Remeron (mirtazapine) ☐ Serzone (nefazodone) ☐ Anafranil (clomipramine) ☐ Pamelor (nortrptyline) ☐ Tofranil (imipramine) ☐ Elavil (amitriptyline) ☐ Other: Mood Stabilizers ☐ Lithobid (lithium) ☐ Depakote (valproate) ☐ Tegretol (carbamazepine) ☐ Lamictal (lamotrigine) ☐ Trileptal (oxcarbamazepine) ☐ Topamax (topiramate) ☐ Neurontin (gabapentin) ☐ Other: Antipsychotics/Mood Stabilizers ☐ Seroquel (quetiapine) ☐ Zyprexa (olanzepine) ☐ Geodon (ziprasidone) ☐ Latuda (lurasidone) ☐ Risperdal (risperidone) ☐ Invega (paliperidone) ☐ Clozaril (clozapine) ☐ Haldol (haloperidol) ☐ Prolixin (fluphenazine) ☐ Abilify (aripiprazole) ☐ Other:
Sedative/Hypnotics ☐ Ambien (zolpidem) ☐ Lunesta (eszopiclone) ☐ Sonata (zaleplon) ☐ Rozerem (ramelteon) ☐ Restoril (temazepam) ☐ Desyrel (trazodone) ☐ Belsomra (suvorexant) ☐ Other: Antianxiety medications ☐ Xanax (alprazolam) ☐ Ativan (lorazepam) ☐ Klonopin (clonazepam) ☐ Valium (diazepam) ☐ Tranxene (clorazepate) ☐ Buspar (buspirone) ☐ Other: ADHD medications ☐ Ritalin (methylphenidate) ☐ Concerta (methylphenidate) ☐ Focalin (dexmethylphenidate) ☐ Adderall (amphetamine) ☐ Vyvanse (lisdexamfetamine) ☐ Strattera (atomoxetine) ☐ Other:
PSYCHIATRY
Current MEDICATIONS
List all prescribed medications you are currently taking
Prescribed Medication Name Daily dose Reason How long? Given by Dr.
List any OTC medications, vitamins, supplements you are taking and why:
Vitamin/Supplement Name Reason Vitamin/Supplement Name Reason
OFFICE USE ONLY
Weight: _________________
Height: _________________ Pulse: _________________ BP: _________________ Taken by: ________________
PSYCHIATRY
WOMEN ONLY Menstrual Period
☐ N/A ☐ Regular ☐ Irregular Type of Birth Control Used: ☐ N/A ☐ Condom ☐ IUD ☐ Pills ☐ Other __________
MEDICAL HISTORY
☐Allergies (seasonal) ☐ Anemia ☐ Asthma ☐ Cancer (explain: _____________________) ☐ Crohn's Disease☐ Chronic Pain (location _____________________) ☐ Diabetes Mellitus
☐ Fibromyalgia ☐ Heart attack (MI) ☐ Hepatitis
☐ Hypercholesterolemia ☐ Hypertension
☐ Irritable bowel syndrome ☐ Renal Insufficiency Syndrome ☐ Liver disease ☐ Low Testosterone ☐ Peripheral Neuropathy ☐ Gastroesophageal Reflux Disease (GERD) ☐ Seizure Disorder
☐ Sleep Apnea (on CPAP? Yes No) ☐ Gastric Ulcer
☐ Stroke (CVA)
☐ Low Thyroid (Hypothyroidism) ☐ Urinary Tract Infection
☐ Other ____________________
ALLERGIES
☐ Aspirin ☐ Bactrim ☐ Erythromycin ☐ Ibuprofen ☐ Morphine ☐ Penicillin ☐ Other ___________________SURGICAL HISTORY
☐ Adjustable Gastric Band ☐ Back Surgery ☐ Breast Surgery ☐ Cancer related ☐ Cardiac Pacemaker Insertion ☐ Cholecystectomy ☐ Colectomy ☐ Gallbladder Surgery ☐ Gastric Bypass ☐ Heart Surgery ☐ Hernia Repair ☐ Hysterectomy ☐ Ileostomy☐ Intrathecal Pump (ITP) ☐ Neck Surgery
☐ Nephrectomy
☐ Spinal Cord Stimulator (SCS)
☐ Splenectomy
☐ Thyroidectomy; Total ☐ Total Hip Replacement ☐ Total Knee Replacement ☐ Tubal Ligation
☐ Vascular Stent ☐ Weight Loss Surgery ☐ Other ______________
PSYCHIATRY
SOCIAL HISTORY
Marital Status Living Arrangements (besides you, who else lives at home?) ☐ Single
☐ Married ☐ Divorced ☐ Widow(er)
Name Age Relation to you
How Long? ____________ Describe your Relationship to Spouse:
Any Prior Marriages? How Long do you live in current place? ☐No ☐Yes (# ________) Where were you living before?
Children Pets ☐ Dog(s) Age(s) _______
☐ Boy(s) Age(s) __________ ☐ Cat (s) Age(s) _______ ☐ Girl(s) Age(s) __________ ☐ Other _______________
Education Occupation How long?
Highest Level of Education?
☐ Student ☐ Working ☐Unemployed ☐Retired ☐On Disability ☐ 0-12 grade Degree/Major:
☐ High school/GED If working, list below:
☐ College Position Where How Long?
☐ Post Grad
☐ Other
List other jobs you have held in the past:
Growing up, did you have:
☐No ☐Yes …any disciplinary problems?
☐No ☐Yes …to repeat any grades?
Military History
☐ N/A ☐ Army ☐ Navy ☐ Air Force ☐ Marines ☐ Other
PSYCHIATRY
Religion Interests/Hobbies/Relaxation
What is your religion affiliation?
What do you do to relax/relieve stress?
How important is it in your life? What interests/hobbies do you have?
Who (else) is your support system? Any physical activity/Exercise? How often?
Stressors
☐No ☐Yes Financial Describe:
☐No ☐Yes Legal Describe:
SUBSTANCE USE HISTORY
Tobacco Use Caffeine Use Alcohol Use ☐ Never smoker ☐ Used to smoke, quit _________ago ☐ Currently smoking ________ ppd ☐ Chewing tobacco ☐ N/A ☐ Coffee (___________/d) ☐ Tea (___________/d) ☐ Soda (___________/d) ☐ Energy Drinks (_______/d) ☐ Never ☐ Quit ________ago ☐ Socially How much? ☐ Beer _________ ☐ Wine _________ ☐ Mixed drinks _________________ ☐ Other __________ Caused Problems? ☐ N/A ☐ DWI ☐ Blackout ☐ Tremors ☐ Other __________ Substances use
Past Present Substance Name Effect on you Last Use Problem? ☐ ☐
Marijuana/weed
☐ ☐Amphetamine/Speed
☐ ☐Cocaine/Crack
☐ ☐Heroin/Opiates
☐ ☐PCP
☐ ☐LSD
☐ ☐Other: ________________
Treatment? ☐ N/A ☐ AA groups ☐ NA groups ☐ Sponsor ☐ Outpatient ☐ Inpatient
