PATIENT INTAKE / HISTORY FORM PATIENT INFORMATION

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Clementine Scott
10 years ago
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1 Mona Mikael, Psy.D., PSY Neuro- Rehabilitation Psychologist Neuro- Rehab Psychological Consultation & Treatment 630 S. Raymond Ave., #340 Pasadena, CA Web: e Mail: [email protected] PATIENT INTAKE / HISTORY FORM PATIENT INFORMATION Name: DOB: Address: City/State: Zip Code: Home phone: Cell phone: Work phone: 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: Page 1

com PATIENT INTAKE / HISTORY FORM PATIENT INFORMATION Name: DOB: Address: City/State: Zip Code: Home phone: Cell phone: Work phone: Email: DESCRIBE YOUR RELATIONSHIP TO THE PATIENT Self Parent Family

2 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? Page 2

disorder Allergies? Other Medical Problems?

3 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 Have you ever been arrested? yes no Ever been to prison? yes no Page 3

Yes No Were you ever assessed for a learning problem? Yes No How would you describe yourself as a student?

4 PREVIOUS EMPLOYMENT (Attach resume if desired) Page 4

5 COUNSELING Are you seeing a psychotherapist or counselor now? yes no Are you seeing a psychiatrist now? yes no Have you ever in the past? yes no Counselor s Name Number of times you saw this counselor? Was it helpful? yes no How did your life improve? MEDICATIONS NAME DOSE DOCTOR Page 5

6 HEALTH HABITS Do you drink coffee or caffeinated drinks? yes no Do you smoke cigarettes? yes no Use any other tobacco? yes no Have you ever had any other compulsive or addictive problems? yes no Do you think you have or ever had any problems with drugs? yes no Have you ever had a gambling problem? yes no How often do you exercise? Page 6

yes no Have you ever had any other compulsive or addictive problems?

St. Luke s MS Center New Patient Questionnaire. Name: Date: Birth date: Right or Left handed? Who is your Primary Doctor?

St. Luke s MS Center New Patient Questionnaire Name: Date: Birth date: Right or Left handed? Who is your Primary Doctor? Who referred you to the MS Center? List any other doctors you see: Reason you have