University of Florida & Shands Adult Psychiatry Outpatient Clinic Intake Form
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1 University of Florida & Shands Adult Psychiatry Outpatient Clinic Intake Form Date Name Age Address Home phone Work phone Cell phone What issue(s) bring(s) you to the Psychiatry Clinic? What has been stressing you of late (e.g. Family, job, recent loss of loved ones, financial issues)? Are you currently having any of the following problems (please circle)? Depression? Loss of interest in activities? Feeling hopeless, worthless? Poor energy? Poor self-esteem? Change in appetite? Increased or decreased? Fatigue? Poor focus? Problems going to sleep? Thoughts of not being alive? Periods of euphoria or unusually good mood? Having very high energy for no reason? Going days without needing to sleep? Thoughts racing? Talking too fast? Acting impulsively (spending, speeding)? Worrying excessively? Having tense muscles? So anxious you feel you cannot rest? Having panic attacks? Traumatic events that come back in nightmares, flashbacks? Feeling awkward in public? Thoughts that replay? Repetitive or compulsive behaviors? Phobias or fears? Grunts, tics, or jerks? Inattentiveness at work or school? If so, since what age? Hyperactive or fidgety? Hearing voices? Seeing things? Feelings people were trying to watch or harm you? Concerns about alcohol use? Drug use? Concerns about eating too much? Eating too little? Memory problems? Getting lost easily? Forgetting how to do tasks? Problems finding words? Problems caring for yourself (cooking, dressing)? 1
2 Past Psychiatric Care Have you been ever diagnosed with a mental health condition by a medical provider (e.g. Depression, bipolar, schizophrenia, ADHD)? If so, please list. Have you ever been seen by a psychiatrist or therapist/counselor? Please list and describe. Date(s) seen? By whom? For what problem? What treatment (meds, ECT, therapy)? Have you ever been hospitalized for psychiatric care? Please list and describe. Date(s) Where and for what? What treatment (meds, ECT, therapy)? Have you ever been treated with any of the following medications? Circle all that apply and list any good or bad effects of the medications. Med Good/bad effects Med Good/bad effects Med Abilify Haldol Ritalin Ambien Klonopin Saphris Adderall Invega Serax Anafranil Lamictal Seroquel Antabuse Latuda Serzone Ascendin Lexapro Soma Atarax Librium Sonata Ativan Lithium Stelazine Buspar Lunesta Strattera Good/bad effects 2
3 Campral Luvox Suboxone/ subutex Celexa Marplan Symmetrel Chloral Mellaril Tegretol hydrate Clonidine Methadone Thorazine Clozaril Miltown Tofranil Cogentin Nardil Topomax Concerta Norpramine Traxene Cymbalta Orap Trazodone Dalmane Pamelor Trileptal Depakote Parnate Valium Dexedrine Paxil Vibryd Doral Prosom Vistraril Effexor Pristiq Vivitrol Elavil Prolixin Wellbutrin Fanapt Remeron Xanax Geodon Restoril Zoloft Halcion Risperdal Zyprexa Any other psychiatric medications you have taken? Past Medical Care Do you have a primary care doctor? Name Last Seen? What medical illnesses do you have? What surgeries have you had? Please list all medications you are currenly taking, including over-the-counter medications, herbals, and supplements. Medication Dosage # times per day For what condition Who prescribes it 3
4 Describe any allergies you have (e.g. to medications, foods). Are you currently having or have you recently had any of these physical symptoms? Fevers Headache Constipation Hot/cold flashes Chills Chest pain Acid reflux Decreased sex drive Night sweats Shortness of breath Joint pains Problems reaching orgasm Unexplained weight loss/gain Heart palpitations Muscle pains or tension Easy bruising or bleeding Weakness in Cough Pain or difficulty Rashes arms/legs urinating Numbness in Sore throat Dental problems arms/legs Episodes of passing Nausea or vomiting Changes in vision out Problems walking Diarrhea Changes in hearing For women- Last menstrual period? Usually regular? Yes/no Do you use any birth control? Yes/no If yes, please list. Have you been pregnant before? Yes/no If yes, how many times? Miscarriages? Yes/no Elective abortions? Yes/no Any depression or unreal thoughts around pregnancies? Yes/no Substance Use History How often have you used the following substances? Tobacco Alcohol Marijuana or K2/"spice" Cocaine Opiates (e.g. Heroin, morphine, Percocet, Last time used? Approximately how often (# of times per week, month or year)? How much do you use in a sitting if/when you do use? 4
5 oxycodone, Tylenol #3, Dilaudid/hydromorphone) Tranquilizers/sedatives (e.g. Xanax, Ativan, Klonopin, Valium) PCP or LSD Mushrooms Others Family History Please list blood relatives who have been diagnosed with the following conditions. Alcoholism Anxiety disorders Bipolar disorder Cancer Depression Diabetes Drug abuse Heart disease/high blood pressure/arrhythmias Osteoporosis Seizures Schizophrenia Strokes Suicides Thyroid disease Social History Where do you live? Who lives with you? How far did you go in school/highest level of education? What is your current job/occupation? What jobs have you had in the past? Are you married? Yes/no If so, for how long? 5
6 Have you been married in the past? Yes/no # of times? Do you have children? Yes/no If so, how many, what are their ages? What do you do in your free time to relax? Do you have any religious beliefs? Yes/ No How important are your religious/spiritual beliefs to your life? Have you had any legal issues (arrests, charges, time in jail)? If so, please describe. Have you ever been the victim of a violent crime? Yes/No Have you ever been a victim of physical abuse? Emotional? Sexual abuse or rape? If so, please explain. Safety Do currently have thoughts of hurting yourself? Yes/no Please explain. Have you tried to hurt yourself in the past? If so, please explain. Do you currently have thoughts of hurting anyone else? Yes/no Please explain. Have you tried to hurt anyone in the past? If so, please explain. Do you own any guns or knives? 6
7 Name Provider Date Patient ID #
8 The Epworth Sleepiness Scale (ESS) How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation: 0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing SITUATION CHANCE OF DOZING (0 3) Sitting and reading Watching television Sitting inactive in a public place (e.g. a theater or meeting) As a passenger in a car for an hour without a break Lying down to rest in the afternoon when circumstances permit Sitting and talking to someone Sitting quietly after a lunch without alcohol In a car, while stopped for a few minutes in the traffic TOTAL SCORE SCORE RESULTS: 1-6 Congratulations, you are getting enough sleep! 7-8 Your score is average 9 and up Very sleepy and should seek medical advice Johns, M.W. (1991). A new method for measuring daytime sleepiness: The Epworth sleepiness scale. Sleep, 14, Permission for single-use of the information contained in this material was obtained from the Associated Professional Sleep Societies, LLC, September Copyright MW Johns Used under license. general assessment series Best Practices in Nursing Care to Older Adults A series provided by The Hartford Institute for Geriatric Nursing, New York University, College of Nursing hartford.ign@nyu.edu HARTFORD INSTITUTE WEBSITE CLINICAL NURSING WEBSITE
9 CHECKLIST: Review of Systems Patient Name: Date of visit: CONSTITUTIONAL: Weight Loss Fatigue Fever EYES: Glasses/Contacts Eye Pain Double Vision Cataracts EAR,NOSE,THROAT: Difficulty Hearing Ringing in Ears Vertigo Sinus Trouble Nasal Stuffiness Frequent Sore Throat CARDIOVASCULAR: Murmur Chest Pain Palpitations Dizziness Fainting Spells Shortness of Breath Difficulty lying Flat Swelling Ankles ENDOCRINE: Loss of Hair Heat/Cold Intolerance RESPIRATORY: Cough Easy Coughing Blood Wheezing Chills GASTROINTESTINAL: Heartburn/Reflux Nausea/Vomiting Constipation Change in BMs Diarrhea Jaundice Abdominal Pain Black or Bloody BM GENITOURINARY: Burning/Frequency Nighttime Blood in Urine Erectile Dysfunction Abnormal Discharge Bladder Leakage ALLERGIC/IMMUNOLOGIC: Hives/Eczema Hay Fever PSYCHIATRIC: Anxiety/Depression Mood Swings Difficult Sleeping HEMATOLOGY/LYMPH: Easy Bruising Gums Bleed Easily Enlarged Glands MUSCULOSKELETAL: Joint Pain/Swelling Stiffness Muscle Pain Back Pain SKIN: Rash/Sores Lesions Itching/Burning NEUROLOGICAL: Loss of Strength Numbness Headaches Tremors Memory Loss FEMALES ONLY: Date Last Mammogram Normal Abnormal Date last PAP Normal Abnormal Age Onset Periods Age Onset Menopause Periods Regular? Yes No Number Pregnancies
University of Florida & Shands Adult Psychiatry Outpatient Clinic Intake Form
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