PSYCHIATRY. Patient Name: Date: / / Date of Birth: / / Age: Pharmacy Name: Pharmacy Phone #:

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1 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 Other Providers (specialty): Family member Friend Therapist PCP Other What are the problem(s) you are seeking help for? Date of Onset 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 Page 1 of 7

2 REVIEW OF SYSTEMS Please, check if you had experienced any of the symptoms below, this past week General: Fever HEENT: Dry Mouth Cardiovascular: Palpitations Musculoskeletal: Joint Stiffness Chills Bleeding Gums Chest Pain Joint Swelling Night Sweats Snoring Leg Swelling Back Pain Weight Change Blurred Vision Irregular Heart Beat Muscle Weakness Hearing Loss Skin: Ringing In Ear Gastrointestinal: Neurological: Rash Nose Bleeding Nausea Headaches Itching Vomiting Tremors Easily Bruising Respiratory: Diarrhea Dizzy Hair Loss Cough Constipation Lightheaded Snoring Stomach Ache Fainting Neck: Difficulty Breathing Bloating Numbness Neck Pain Bloody Stool Neck Stiffness Neck Swelling 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? Page 2 of 7

3 Check if you have ever taken any of the following medications: Antidepressants Prozac (fluoxetine) Brintellix (vortioxetine) Serzone (nefazodone) Zoloft (sertraline) Luvox (fluvoxamine) Paxil (paroxetine) Celexa (citalopram) Lexapro (escitalopram) Viibryd (Vilazodone) Effexor (venlafaxine) Cymbalta (duloxetine) Pristiq (desvenlafaxine) Fetzima (levomilnacipran) Wellbutrin (bupropion) Remeron (mirtazapine) Anafranil (clomipramine) Pamelor (nortrptyline) Tofranil (imipramine) Elavil (amitriptyline) Mood Stabilizers Lithobid (lithium) Depakote (valproate) Tegretol (carbamazepine) Lamictal (lamotrigine) Trileptal (oxcarbamazepine) Topamax (topiramate) Neurontin (gabapentin) Antipsychotics/Mood Stabilizers Seroquel (quetiapine) Zyprexa (olanzepine) Geodon (ziprasidone) Abilify (aripiprazole) Latuda (lurasidone) Risperdal (risperidone) Invega (paliperidone) Clozaril (clozapine) Haldol (haloperidol) Prolixin (fluphenazine) Sedative/Hypnotics Ambien (zolpidem) Lunesta (eszopiclone) Sonata (zaleplon) Rozerem (ramelteon) Restoril (temazepam) Desyrel (trazodone) Belsomra (suvorexant) Antianxiety medications Xanax (alprazolam) Ativan (lorazepam) Klonopin (clonazepam) Valium (diazepam) Tranxene (clorazepate) Buspar (buspirone) ADHD medications Ritalin (methylphenidate) Concerta (methylphenidate) Focalin (dexmethylphenidate) Adderall (amphetamine) Vyvanse (lisdexamfetamine) Strattera (atomoxetine) Page 3 of 7

4 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: Page 4 of 7

5 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 PSYCHIATRY ALLERGIES Aspirin Bactrim Erythromycin Ibuprofen Morphine Penicillin Other WOMEN ONLY Menstrual Period N/A Regular Irregular Type of Birth Control Used: N/A Condom IUD Pills 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 Page 5 of 7

6 SOCIAL HISTORY Marital Status Single PSYCHIATRY Living Arrangements (besides you, who else lives at home?) Name Age Relation to you Married Divorced Widow(er) How Long? Describe your Relationship to Spouse: Any Prior Marriages? No Yes (# ) How Long do you live in current place? Where were you living before? Children Pets Dog(s) Age(s) Boy(s) Age(s) Girl(s) Age(s) Cat (s) Age(s) Other Education Occupation How long? Highest Level of Education? 0-12 grade Degree/Major: High school/ged Student Working If working, list below: Unemployed Retired On Disability 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 Highest Rank Type of Discharge % Disability Page 6 of 7

7 Religion What is your religion affiliation? Interests/Hobbies/Relaxation 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, N/A Coffee ( /d) Never Quit ago quit ago Tea ( /d) Socially Currently smoking ppd Chewing tobacco Soda ( /d) Energy Drinks ( /d) 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 Treatment? N/A AA groups NA groups Sponsor Outpatient Inpatient **Thank you for filling this form out. Please, make sure you bring it to your appointment*** Page 7 of 7

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