Early Morning Waking Excessively Orderly or Perfectionistic

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1 COLLEGE OF MEDICINE Jacksonville 580 W 8 th St T-2 6 th Fl Ste Dupont Station Ct Department of Psychiatry Jacksonville, FL Jacksonville, Fl Division of Adult Psychiatry Phone Phone Fax Fax Date of Appointment: Age: Today s Date: Name: Preferred Name: Date of Birth: Referred By: What Are Your Concerns That Brought You In Today? Adult Patient History Questionnaire Please Circle All Symptoms That You Are Currently Experiencing: Sad Mood Racing Thoughts Panic Attacks Excessive Dieting Low Concentration/Memory Fear of Leaving the Focused on Body Weight or Image Energy/Fatigue Difficulties House Hopelessness Increased/Decreased Fear of Driving Change in Weight Sexual Interest Guilt Decreased Appetite Fear of Specific History of Trauma/Victim of Abuse Situations/Things Worthlessness Increased Appetite Fear of Being in Offender of Abuse Public Crying Spells Difficulty Falling Upsetting Thoughts Hearing Voices Others Do Not Asleep Decreased Excessive Sleeping Repetitive Thoughts Seeing Images Others Do Not Motivation or Behaviors Loss of Interest in Usual Activities Early Morning Waking Excessively Orderly or Perfectionistic Bizarre Ideas 1

2 Irritability Suicidal Thoughts Periods of Lost Time Hyperactivity Thoughts of Harming Excessive Anger / Others Aggressiveness Impulsiveness Self Harm/Cutting Difficulty Trusting Others Elevated Mood Anxious/Worried Binge Eating / Purging Recent Upsetting Change or Loss Alcohol Abuse Drug Abuse Overuse of Prescription Medication Medications: Please list all medications or supplements that you are currently taking. Include psychiatric and medical medications. Medication Dose (mg, units,ml, etc) Doses per day (AM, twice daily, at bedtime, etc) Have you experienced a head injury? If so, please explain what happened, your age, and if you were unconscious: Primary Care Physician: Clinic Address and Phone Number: Current Medical Diagnoses i.e. asthma, diabetes, seizures, etc 4. Treatment? Previous Surgeries Approximate Date Location/Hospital Previous Hospitalizations Approximate Date Location/Hospital Medication Allergies: Food Allergies: 2

3 Past Psychiatric History Have you ever seen a psychiatrist? If so, please provide information about providers, dates, and treatment rendered. Have you ever seen a psychologist? Have you ever seen a therapist (i.e. LMHC, LCSW, LMFT)? Have you ever been hospitalized for psychiatric reasons? If so, where and when? Developmental History: Any Learning Disabilities (i.e. reading, dyslexia, writing, math, etc)?: Attended Special Education Classes?: Received Any Developmental Services (i.e. physical, speech, occupational therapy, etc)?: Social History: Marital Status: Single Married Divorced Widowed Partnered Lives With (Name, Age, and Relation to Yourself): Highest Grade Attended: Occupation and Employment (specialty, where you work, and how long): Military History: Arrest History or Pending Legal Issues (i.e. divorce, disability, bankruptcy, etc): 3

4 Family History: Please indicate if there is a family history of the following conditions and WHO is affected with the condition. Anxiety Heart disease Depression Bipolar disorder ADHD Autism Eating Disorders Learning disabilities Other psychiatric conditions? Sudden cardiac death Cancer Alcoholism Drug abuse Thyroid problems Seizures Other medical conditions? Substance Abuse History: Please circle all that you have used in the past 2 years: Alcohol Marijuana (weed) Cocaine (crack, coke) Tobacco Opiates (heroin, pain killers, methadone) Benzodiazepines (Xanax, Klonipin, Ativan, Valium) MDMA (ecstasy) LSD (acid, hallucinogens) Over the Counter (cough syrup, triple C s) Bath Salts, Spice, K2 Amphetamines (speed, Adderall, Ritalin) Inhalants (dusters, whip its) Other: Other: In the past two years, there have been one or more episodes of memory loss due to substance abuse? Yes or No There are personality changes due to the use of substances. Yes or No In the past 5 years, there has been one or more arrest due to substance or alcohol use? Yes or No Someone close to you thinks you may have a serious substance abuse problem. Yes or No There is a history of serious problems with the use of substances. Yes or No There is a history of substance abuse treatment. Yes or No 4

5 Past Psychiatric Medication Anti Depressants Amitriptyline (Elavil) Bupropion (Wellbutrin) Citalopram (Celexa) Clomipramine (Anafranil) Desipramine (Norpramin) Doxepin (Sinequan) Escitalopram (Lexapro) Fluoxetine (Prozac) Fluvoxamine (Luvox) Imipramine (Tofranil) Mitrazapine (Remeron) Nefazodone (Serzone) Nortriptyline (Pamelor) Paroxetine (Paxil) Phenelzine (Nardil) Dexvenlafaxine (Pristiq) Sertraline (Zoloft) Tranylcypromine (Parnate) Trazodone (Desyrel) Venlafaxine (Effexor) AntiAnxiety Alprazolam (Xanax) Buspirone (Buspar) Chlordiazepoxide (Librium) Clonazepam (Klonopin) Clorazepate (Tranxene) Diazepam (Valium) Flurazepam (Dalmane) Hydroxyzine (Vistaril) Lorazepam (Ativan) Oxazepam (Serax) Temazepam (Restoril) Triazolam (Halcion) Zolpidem (Ambien) Response (Good, Fair, Poor) Antipsychotic Olanzapine (Zyprexa) Perphenazine (Trilafon) Pimozide (Orap) Quetiapine (Seroquel) Risperidone (Risperdal) Asenapine (Saphris) Thioridazine (Mellaril) Thiothixene (Navane) Trifluperazine (Stelazine) Mood Stabilizers Carbamazepine (Tegretol) Gabapentin (Neurontin) Lamotrigine (Lamictal) Lithium (Lithobid, etc) Topiramate (Topamax) Valproic Acid (Depakote, etc) ADHD Medications Amphetemine salts (Adderall, etc) Clonidine (Kapvay, Catapres) Dexmethylphenidate (Focalin) Guanfacine (Intuniv, Tenex) Methylphenidate (Ritalin, Concerta, Daytrana, etc) Strattera (Atomoxetine) Vyvanse (Lisdexamfetamine) Miscellaneous Thyroid (Synthroid, Cytomel) Dilantin (Phenytoin) Propranolol (Inderal) Naltrexone (Revia) Benztropine (Cogentin) Trihexyphenidyl (Artane) L-Dopa Response (Good, Fair, Poor) Antipsychotic Aripiprazade (Abilify) Fluphenazine (Prolixin) Haloperidol (Haldol) Lurasidone (Latuda) Other Medications 5

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