General Information. Who referred you to our service? Please provide contact information:
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1 General Information Date: Date of Birth: Age: Full Name: Address (include zip): Phone: Home: Is it okay to leave a detailed message at this number? Yes No Cell: Is it okay to leave a detailed message at this number? Yes No E- Mail Address: Do I have your consent to an appointment reminder prior to sessions? Yes No Do I have your consent to digital copies of: 1) Records: Yes No 2) Billing statements: Yes No Emergency contact name: Phone #: Address: Please tell us a little more about you: Gender: Ethnicity/Cultural identity: Spiritual beliefs: Disability (if any): Sexual orientation: Occupation and/or School & Major: Handedness (right/left/ambidextrous): Who referred you to our service? Please provide contact information: Is this referral a result of or related to any legal or court proceedings? If so please provide name of attorney. Please list the reason(s) you are seeking services: How long have these problems occurred? (number of weeks, months, years) Please list any other healthcare providers involved in your care (e.g., neurologists, other physicians, occupational therapists, etc.):
2 Developmental/Medical History Medical History Has your medical history been normal/unremarkable? If no, please explain: Have you received any medical diagnoses? Please explain: Have you completed genetic testing? Have you had an MRI? Have you had an EEG? Frequent ear infections? Were ear tubes ever placed? Hearing problems? Vision problems? Headaches? Meningitis? Seizures? Asthma? Slow/fast growth? Head injury? Allergies? Hospitalizations? Have you experienced anything you would call traumatic (physical, verbal, or emotional abuse; unwanted sexual experiences; accidents or other events)? Have you ever been hospitalized, had surgeries, or major illnesses? Age How long Reason What medications do you currently take? (Include over- the- counter supplements) Name Dose Frequency Reason Describe your sleep routine: Typical bed time: Typical wake time: Trouble falling asleep? Trouble staying asleep? Trouble waking up early? Any other sleep problems? Explain: Describe your diet: Describe your current level and type(s) of exercise: Page 2 of 5
3 Mental Health History List any previous or current mental health diagnoses: Have you received therapy services or counseling in the past? Yes No Are you currently seeing a psychiatrist for medication? Have you in the past? Name of Psychiatrist: Dates of treatment: Medication the Psychiatrist Prescribed: Is there a history of self- harm or suicidal thoughts, threats, or attempts? Please explain: Have you ever been hospitalized for mental health concerns? Please explain: Describe your personality: Psychosocial Functioning What are your non- academic strengths? What are your non- academic weaknesses? How do you spend your free time? What is your current level of alcohol and/or drug use? Alcohol: Recreational drugs: How is your social group? Do you have close friends? Any trouble initiating or maintaining relationships? Page 3 of 5
4 Please place a mark next to behaviors that you believe you experience to an excessive or exaggerated degree when compared to others your age. Sleeping and Eating Nightmares Trouble falling asleep Trouble staying asleep in the morning Decreased need for sleep without getting tired Eats Poorly Eats excessively Excessive snoring during sleep Social Prefers to be alone Excessively shy or timid More interested in objects than people Difficulty making friends Not sought out for friendship by peers Excessive daydreaming and fantasy life Difficulty seeing another person s point of view Trouble empathizing with others Overly trusting of others Trouble understanding/enjoying humor Behavior Stubborn Irritable, angry, or resentful Strikes out at others Throws or destroys things Lying Stealing Argues with others Low frustration threshold Daredevil behavior Impulsive (does things without thinking) Motor Skills Poor fine motor coordination Poor gross motor coordination History of vocal or motor tics Poor sense of danger/risk Cries frequently Excessively worried and anxious Overly preoccupied with details Overly attached to certain objects Not affected by negative consequences Drug abuse Alcohol abuse Clumsy in general Legal History Have you been involved with the court currently or in the past? Date(s): Describe: Current Probation? Probation Officer: Phone #: Family History Are you (choose one): Married Separated Divorced Living Together Single If married, for how long? If separated or divorced, when? Do you have children? Ages? Page 4 of 5
5 Who else lives in your home? Have any of the following diseases occurred among your blood relatives (parents, aunts, uncles, grandparents)? Check those that apply: Allergies Deafness Intellectual Amnesia Diabetes disability/cognitive Asthma Glandular problems delay ADHD Heart diseases Seizures Bleeding tendency High blood pressure Cerebral Palsy Depression Kidney disease Migraines Cancer Alcohol/drug problem Muscular Dystrophy Suicide Anxiety Other (specify): Learning problems Autism/Asperger s Page 5 of 5
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1 of 6 6/3/2014 10:15 AM Return to Web version Depression Overview What is depression? When doctors talk about depression, they mean the medical illness called major depression. Someone who has major depression
Cocaine. Like heroin, cocaine is a drug that is illegal in some areas of the world. Cocaine is a commonly abused drug.
Cocaine Introduction Cocaine is a powerful drug that stimulates the brain. People who use it can form a strong addiction. Addiction is when a drug user can t stop taking a drug, even when he or she wants
Documentation Requirements ADHD
Documentation Requirements ADHD Attention Deficit Hyperactivity Disorder (ADHD) is considered a neurobiological disability that interferes with a person s ability to sustain attention, focus on a task
Marian R. Zimmerman, Ph.D.
Marian R. Zimmerman, Ph.D. Clinical Health Psychology www.mzpsychology.com 3550 Parkwood Blvd., 306 (214)618-1451 Phone Frisco, TX 75034 (214)618-2102 Fax Pre-Surgical Evaluation Patient Name: Age: Date
JAMES PETROS, M.D., INC. PHONE: (408) 528-8833 FAX: (408) 528-8557
FIGHTING PAIN. TOUCHING LIVES. JAMES PETROS, M.D., INC. PHONE: (408) 528-8833 FAX: (408) 528-8557 Personal Information Emergency Contact Today s Date: Name: Patient: Realtionship: Birth Date: Age: Sex:
Name Last) (First) ( (M.I.) Birth Date Social Security Age Sex: Home Address. City State Zip. Complaint/ Area to be treated Email Address
PLEASE PRINT CLEARLY : NEW PATIENT FORM Name Last) (First) ( (M.I.) Birth Social Security Age Sex: M / F Home Address City State Zip Complaint/ Area to be treated Email Address Home Phone ( ) Drivers Lic
AGREEMENT AND INFORMATION
AGREEMENT AND INFORMATION We would like to welcome you to our office. Please review this Agreement and Information sheet to assist you in understanding our office policies. Our therapists are private practitioners.