ADULT FEMALE NEW PATIENT INFORMATION FORM

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1 The Fort Christian Psychiatric Center Shaw Wendi Fortuchang, M.D., P.C. ADULT FEMALE NEW PATIENT INFORMATION FORM How were you referred to our office? Patient s Full Name Age: Date of Birth: Gender: Address: Home Number: Mobile Number: May we leave messages for you at these numbers? No Yes Please indicate the best number to reach you: Home Mobile Work Home Address: City: State: Zip: With whom do you live? Name of person filling out this form (if not patient): Indicate your relationship to the patient May we send courtesy appointment reminders to the above address? No Yes May we inspirational Christian devotionals to you? No Yes Level of Education: Highest Degree Earned: Are you currently a student? No Yes Full-Time Part-Time If yes, what is the name of your school? What year are you in school? Are you currently employed? No Yes Full-Time Part-Time Retired Looking If no, what type of work did you do when you were employed? Patient s Employer: Type of Work: Patient s Work Phone: How long have you worked here? Are you married? Yes No Engaged Separated Divorced Widowed Spouse s Full Name: Spouse s Age: DOB: Spouse s Employer: Spouse s Type of Work: Spouse s Work Phone: Spouse s Mobile Phone: Spouse s Highest Level of Education: 1

2 Name and relationship to EMERGENCY CONTACT person: Phone Numbers: Home Mobile Work Primary Care Doctor Name of doctor and practice: Address: Phone Number: Fax Number: Preferred Pharmacy Information Name: Location: Phone Number: Please describe the primary reason for today s appointment: Past Psychiatric History Have you ever been treated by a psychiatrist? Yes No When/Why/Where/How long? Were you given a diagnosis? Yes No If yes, what? Psychiatrist s name: Have you ever been in counseling with a therapist? Yes No When/Why/Where/How long? Therapist s name: Have you EVER been prescribed any psychiatric medication? Yes No Please circle all medications you have EVER been prescribed Prozac, Paxil, Zoloft, Celexa, Lexapro, Effexor, Pristiq, Cymbalta, Wellbutrin, Buspar, Remeron, Trazodone, Elavil, Luvox, Xanax, Klonopin, Valium, Ativan, Risperdal, Zyprexa, Seroquel, Abilify, Geodon, Lithium, Depakote, Tegretol, Trileptal, Lamictal, Neurontin, Topamax, Ambien, Lunesta, Rozerem, Restoril, Adderall, Concerta, Ritalin, Focalin, Vyvanse, Strattera, Provigil, Namenda, Aricept, Intuniv, Clonidine, Guanfacine, Latuda, Brintellix, Viibryd, Haldol, Halcion, Lyrica, Other What psychiatric medication(s) are you currently taking? Have you ever been hospitalized for psychiatric reasons (including drug and/or alcohol)? Yes No If YES, please describe when, where and why: 2

3 Suicide History Are you currently depressed? Yes No Are you having thoughts of suicide right now? Yes No Have you ever had thoughts about suicide? Yes No Have you had suicidal thoughts in the past? Yes No Have you ever attempted suicide? Yes No If YES to any, please explain further: Have you engaged in self-injurious behaviors like cutting, burning, etc.? Yes No If YES, when was the last time? Injury to Others Have you ever thought about hurting someone else? Yes No If YES, please describe further: Recent Stressful Life Events Please circle any of the following events that have occurred in the last 2 years: Married Engaged Separated Divorced Marital Discord Bullied Breakup of Important Relationship Child Left Home Death of a Loved One Serious Health Issues of a Loved One Difficulties with Family Members Sexual Difficulties Work/School Changes or Difficulties Personal injury/illness Retired Lost Job/Fired/Let Go Recent Move Legal Difficulties Major Debt Other Financial Issues Birth of a Child Domestic Issues Spiritual Issues Unrepented sin Unforgiveness Special Needs Child Custody Battle Restraining Order Other I have not experienced any of these concerns Substance Use History Alcohol Use: How many drinks do you consume on average in a week? What is your drink of choice? Check all of the following that apply to you: Has anyone ever told you that you were drinking too much? Have you ever tried to cut down on your drinking? Have you ever gotten annoyed at people telling you to cut down? Have you ever felt guilty about your drinking? Have you ever needed a drink in the morning to get you going? Have you ever been diagnosed with alcoholism OR drug dependence? Have you ever received treatment/rehab for alcoholism or/and drug dependence? If YES, when and where you treated? Drug Use: Check any of the following drugs you have EVER taken or tried: None Marijuana Amphetamines/Speed/Meth Heroin/Opiates PCP LSD/hallucinogens/mushrooms Cocaine/Crack Benzos/Barbiturates/Sedatives/Downers If checked any of the above, please describe further: 3

4 Spirituality Do you and your family regularly attend church? No Yes Is it a Bible-believing church? No Yes Unsure If yes, please provide the church s name How would you describe your relationship with Christ? Is prayer an integral part of your life? No Yes Do you believe in the power of prayer? No Yes How do you define sin? How do you define repentance? Are there any areas of unrepented sin in your life that could be blocking God s best for you? No _Yes _ If yes, please describe: Are there any areas of unforgiveness in your life? No Yes If yes, please describe: Are you aware that unresolved/unrepented spiritual issues negatively impact a person s emotional, mental, psychological and physical wellbeing? No Yes Unsure Do you believe that Jesus died for your sins and rose for your victory, your salvation, and for you to change from sinner to saved? No Yes Unsure Are you saved? No Yes Unsure Do you believe that because you are saved, you have power over sin? No Yes Unsure Do you believe that Jesus is more powerful than any sin? No Yes Unsure What is your favorite verse of scripture? Please write it in its entirety: Your Social History What do you like to do for fun? What are your hobbies? Are you involved in any groups or organizations? Yes No Which ones? How do you relieve stress? Are you physically active / do you exercise? Yes No Your Birth History Please check the following that pertains to you: My mother s pregnancy with me was normal My mother s delivery of me was abnormal My mother s pregnancy with me was abnormal I do not have this information Your Childhood Please check all of the following that pertained to you during childhood: Afraid to go to school Ran away from home Cruel to animals Set fires Often lied to family and others Oppositional to authority Frequent falls Seizures Disrespectful/Destructive to the property of others Bedwetting after age 5 Tics Frequent transitions (family moved a lot, changed schools a lot, etc) Nightmares Promiscuity Difficulty with reading, writing, mathematics Abuse / Incest Truant from school Failed or repeated a grade Disturbed sleep Fear of the dark Awkward at games or other social activities Trouble with eyesight Left-handed Mispronounced words/had a lisp/stuttered/stammered None of these pertained to me 4

5 Family History Were you adopted? No Yes Where were you born and raised? Who raised you? Who lived in the home where you grew up? Describe what it was like growing up in your home environment: Was it a stable and healthy environment? Yes No Did you have a happy childhood? Yes No Family Psychiatric, Medical and Substance Abuse History Biological Mother: (List all conditions including medical, psychiatric, neurologic, alcoholism, drug abuse, suicide, and suicide attempts. Please indicate N/A if not applicable): Biological Father: (List all conditions including medical, psychiatric, neurologic, alcoholism, drug abuse, suicide, and suicide attempts. Please indicate N/A if not applicable): Full and/or Half Brothers (List all conditions including medical, psychiatric, neurologic, alcoholism, drug abuse, suicide, and suicide attempts. Please indicate N/A if not applicable): Full and/or Half Sisters (List all conditions including medical, psychiatric, neurologic, alcoholism, drug abuse, suicide, and suicide attempts. Please indicate N/A if not applicable): Legal History Have you ever been arrested for ANY reason? Yes No If YES, please indicate the year(s), the charge(s): If YES, did you spend any time in jail? Yes No Prison? Yes No Medical History Height and Weight: What is your current weight in pounds? What is your height? Sleep: Check all of the following that apply to your sleep: Difficulty falling asleep Difficulty staying asleep Feeling tired upon wakening Bad dreams/ Nightmares/ Wet Bed/ Sleepwalk/ Other disturbances Smoking: Do you smoke cigarettes, cigars or other forms of tobacco? No Yes Which ones? If yes, then explain how much and for how long Caffeine: Coffee? No Yes Tea? No Yes Soda? No Yes Do you consume energy drinks like Red Bull, Monster, etc? No Yes If YES to any of the above, how much and how often? Current Medications, Allergies and Medical Conditions Please list all allergies, including allergies to medications (if none, indicate N/A ): 5

6 List ALL current medications, including over- the counter medications and herbal supplements: Who prescribed your medication? What medical conditions do you have currently? Please check all that apply: Diabetes High Blood Pressure High Cholesterol Neurological Issues Liver Problems Headaches Seizure Disorder Endocrine Problems (hormones) Thyroid Issues Anemia Heart Problems Kidney Problems Pain Joint Problems Eye Problems Musculoskeletal Issues Sinus Issues Allergies Skin Problems Gynecologic Issues Gastrointestinal Issues Sexually Transmitted Diseases Dental Issues Lung Problems Please elaborate further on your medical problems: What surgical procedures have you had? Have you ever been involved in any accidents? Have you ever hit your head and lost consciousness? No Yes Have you ever had a CT scan? Yes No Have you ever had an MRI? Yes No Have you ever had a seizure? No Yes Female Reproductive History What was your age at your first menstrual period? What grade were you in? Do you have regular menstrual periods? No Yes If no, then please explain Do you have atypical pain or discomfort with your periods? No Yes If yes then please explain Check all of the following that apply to you during your period: Excessive mood changes Excessive irritability Depression If yes, to any of the above, please describe circumstances: Are you currently taking an oral contraceptive? No Yes If yes, indicate which one and for how long: If YES, does it affect your mood in any way? No Yes If yes, please indicate how Are you currently pregnant? Yes No Have you ever been pregnant? Yes No Number of pregnancies: Did you plan your pregnancy? Yes No Were you happy about the pregnancy? Yes No Did pregnancy affect your moods? Yes No Have you ever miscarried? Yes No Have you ever had an abortion? Yes No Have you ever given a child up for adoption? Yes No Number of living children: 6

7 Your Children List your children s ages, gender, whether or not they have EVER been diagnosed with any major medical and/or psychiatric illnesses, and what medication they take. Please indicate N/A if not applicable: Abuse/Trauma History Have you ever been a victim of verbal/emotional abuse? No Yes Have you ever been a perpetrator of verbal/emotional abuse? No Yes If yes to either, please explain: Have you ever been a victim of physical abuse? No Yes Have you ever been a perpetrator of physical abuse? No Yes If yes to either, please explain: Have you ever been a victim of sexual abuse? No Yes Have you ever been a perpetrator of sexual abuse? No Yes If yes to either, please explain: Have you ever been in a situation where you feared that your life, or someone else s life, was in imminent danger? No Yes If yes, please explain Is there any other information you d like to provide that was not asked in this questionnaire? If yes, then please indicate here: 7

8 GUARANTOR INFORMATION (if not patient): Relationship to Patient: Full Name: (First) (MI) (Last) Address: City: State: Zip: Date of Birth: SSN: Gender: Male Female Phone number: Employer's Name/Address: Phone number: I, the undersigned, agree that I am financially responsible for all services provided by The Fort Christian Psychiatric Center. I am aware that office policy requires payment at the time of service. I understand that unpaid balances over 30 days past due may carry a late fee equivalent to 1.5% of the outstanding balance. I understand that outstanding balances over 90 days may be referred to a collection agency. Patient / POA Signature: Date: *This must be the signature of the person signing. It is illegal in the state of Georgia to sign another person's name without Power of Attorney. GUARANTOR AGREEMENT: This agreement will remain in effect until written notice of other payment arrangements are provided to. The current guardian will be responsible for any and all charges incurred prior to receipt of notification of other arrangements. If you wish to change your guarantor information, you must have the appointed guarantor complete a separate agreement with The Fort Christian Psychiatric Center. Our Change of Guarantor forms are available upon request. CONSENT FOR TREATMENT POLICY: I hereby give consent to be treated by physicians and/or mental health professionals associated with The Fort Christian Psychiatric Center. I agree that I am personally responsible for ensuring that all charges for services rendered are paid by myself. I authorize to provide information concerning my treatment to any physician or therapist who referred me to The Fort Christian Psychiatric Center, as well as to any physician/therapist to whom I may be referred following the initial consultative diagnostic evaluation. Patient s Signature Date: *This must be the signature of the person signing. It is illegal in the state of Georgia to sign another person's name without Power of Attorney. Signature of POA: Date: 8

9 ACCEPTANCE OF POLICIES: Dr. Fortuchang is committed to providing professional services of the highest quality and standards. In order to serve her patients efficiently and responsibly, she requires agreements be made as to the policies stated above and to the reiterated ones below. Patients are encouraged to ask questions before signing. I understand that it is my financial responsibility for services provided and that insurance is for my reimbursement. is considered an out of network provider for all insurance companies. If you have insurance and wish to be reimbursed, we can provide you with a superbill at the end of your appointment so you can file with your insurance company. It is your responsibility to file with your insurance company. We do NOT bill your insurance company directly. All reimbursement you obtain from your insurance company is yours. I understand that I will be charged for missed appointments and cancellations with less than 24 hours notice. Your appointment is reserved for you. If you need to cancel an appointment, please notify us as soon as possible. Appointments not cancelled with at least 24 hours notice will be billed at the full cost of the appointment, as outlined above in the Sessions & Fees section. Full payment is due at the time service is rendered. I acknowledge responsibility for all fees incurred. All balances 30 days past due will be deemed delinquent. I understand that unpaid balances over 30 days past due may carry a late fee equivalent to 1.5% of the outstanding balance. I understand that outstanding balances over 90 days may be referred to a collection agency. I understand that delinquent accounts must be paid in full before any future services will be provided. I have read the office policies of, I understand them, I agree with them, and I will abide by them. Patient s Signature: *This must be the signature of the person signing. It is illegal in the state of Georgia to sign another person's name without Power of Attorney. POA Signature: Date: 9

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