Serenity Psychiatry, LLC Mimi Armellino, DO Of Coastal Counseling Associates. Patient History Form
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1 Serenity Psychiatry, LLC Mimi Armellino, DO Of Coastal Counseling Associates Patient History Form Name Date Age DOB SSN Address City State ZIP Patient s Telephone (H) (W) (Cell) Job Title or School Attending Family Physician (PCP)/Telephone Current Therapist/Psychiatrist with Phone/Address Pharmacy Name/Address Who referred you for this evaluation? Describe reason for referral What specific questions would you like answered by this evaluation? THIS FORM HAS BEEN COMPLETED BY: Patient Other If not completed by the patient, please provide the following information: Name Relation to Patient Address Telephone (H) (W)
2 Current Symptom List Please check all that apply or that concern you: (if known, add age symptoms started) Symptoms: Depressed/low mood Lack of interest Lack of pleasure Hopelessness & Helplessness Excessive guilt Emptiness Low esteem Self critical Irritable Anxiety Symptoms Anxious mood Panic Dizzy Fear of going crazy Fear of no escape Related Symptoms Elated/euphoric mood Irritable/Agitated mood Racing thoughts Excessive activity Seeing/Hearing things that are not there ADHD Symptoms Distractible Fidgeting Easily frustrated Poor coordination Restless Impulsive Anger Fogginess Poor concentration Poor memory Circular thoughts Suicidal thoughts Suicidal plan Sleep disturbance Too much sleep Short of breath Rapid heart rate Sense of floating Avoiding crowds House bound Impulsive Risky behavior Excessive spending Inattentive Sensitive Daydreams Sullen Destructive Steals Too little sleep Social withdrawal Early morning awakening Poor appetite Excessive eating Low energy Social withdrawal Seasonal cycles Muscle tension Excessive worry Headaches Bowel disturbance Nightmares Decreased need for sleep PMS Lies Explosive Isolative No sense of fair play Other Symptoms/Issues of concern:
3 Psychiatric History 1. Have you had any prior Outpatient psychological, psychiatric, or neuro-psychological evaluations/treatment? Y / N If yes, please complete this information: a. Name of provider/address/phone b. Name of provider/address/phone 2. Have you had any prior In-patient (hospitalization) evaluations or treatment? Yes No If yes, please complete this information: a. Name of hospital/address Dates/Duration and reason for this evaluation b. Name of hospital/address c. Name of hospital/address Psychiatric Medication List Please circle medications used at any time and list dates if known: Antidepressants Mood Stabilizers AntiPsychotics Amitryptyine (Elavil) Valproic Acid (Depakote, Depakene) Aripiprazole (Abilify) Desipramine (Norpramin) Lamotrigine (Lamictal) Clozapine (Clozaril) Desvenlefaxine (Pristiq) Oxycarbazepine (Trileptal) Haloperidol (Haldol) Doxepin (Sinequan) Gabapentin (Neurontin) Fluphenazine (Prolixin) Duloxetine (Cymbalta) Lithium (Lithobid, Eskalith) Quetiapine (Seroquel) Escitalopram (Lexapro) Carbamazapine (Tegretol) Ziprazadone (Geodon) Citalopram (Celexa) Lurasidone (Latuda) Fluoxetine (Prozac) Olanzapine (Zyprexa) Fluvoxamine (Luvox) Risperidone (Risperdal/Invega) Imipramine (Tofranil) Mirtazipine (Remeron) Nefazadone (Serzone) Nortriptyline (Pamelor) Anxiolytics/Hypnotics Stimulants Paroxetine (Paxil/CR) Alprazolam (Xanax) Dexedrine Phenelzine (Nardil) Buspirone (Buspar) Adderall Selegiline (Emsam) Chlordiazepoxide (Librium) Focalin Sertraline (Zoloft) Diazepam (Valium) Ritalin/Concerta/Metadate Trazodone (Desyrel) Lorazepam (Ativan) Vyvanse Venlefaxine (Effexor/XR) Temazepam (Restoril) Vilazodone (Viibryd) Zolpidem (Ambien) Eszopiclone (Lunesta) Zalepon (Sonata) Ramelteon (Rozerem) Other meds not listed?
4 Developmental History Were you born: On time Prematurely Late Your weight at birth: Lb. Oz. Were there any problems associated with your birth (e.g., oxygen deprivation, unusual birth position) Yes No Explain Circle all that applied to your mother while she was pregnant with you: Accident Alcohol/Drugs/Cigarettes Hazardous Exposure Illness Malnutrition Psychological Issues Other Issues? If known, list all medications (prescribed or over-the-counter) your mother took while pregnant Rate your developmental progress for walking, language, etc by circling the appropriate response: Early Average Late List childhood medical conditions: Did you ever require hospitalization? Medications as a child: Reason Reason Check all that currently apply: AIDS or HIV Allergies Arteriosclerosis Arthritis Blood disorder Brain disease or infection Cancer or chemotherapy Diabetes Hazardous exposure Medical History Head Trauma Heart disease Huntington s disease High Blood Pressure Kidney disease Liver disease Lung disease Malnutrition Meningitis Multiple sclerosis Parkinson s disease Polio Radiation therapy Seizures Senility (Dementia) Stroke or TIA Thyroid disease STD Any other problems Females: have you ever been or are you currently pregnant If so, have you had any medical problems with your pregnancy(ies) Date of your last medical check-up/findings ** Known Drug Allergies
5 Describe any medical hospitalizations or surgeries with dates: List Current medications (include over-the-counter or alternative medications) and dosages (or attach list): Family History Mother Mother s name Is she alive? Yes No Age If no, age and year of death Cause of death? Mother s level of education & occupation(s) Does your mother have a known or suspected psychiatric condition? Briefly describe your mother s health history Father Father s name Is he alive? Yes No Age If no, age and year of death Cause of death? Father s level of education & occupation Does your father have a known or suspected psychiatric condition? Briefly describe your father s health history Family How many brothers and sisters do you have? Brothers Sisters Where are you in the birth order? Are there any unusual problems (physical, academic, psychological) associated with any of your brothers or sisters? Please describe: Who raised you? Any other aspect of the family that you would like to explain?
6 Substance Use History Alcohol I started drinking regularly at age: less than 10 years old over 21 I drink alcohol: rarely or never 1-2 days/week 3-5 days/week Daily I used to drink but stopped (date) Preferred type(s) of drinks Usual number of drinks I have at one occassion My last drink was: less than 24 hours ago hours ago Over 48 hours ago Check all that apply: I can drink more than most people my age and size before I get drunk. I sometimes get into trouble (fights, legal difficulty, problems at work, conflicts with family, etc.) after drinking. I sometimes blackout after drinking. DUI? Dates I have gone through drug or alcohol withdrawal/detox, dates I have been in alcohol or drug inpatient/outpatient treatment w/ dates There is a family history of drug or alcohol use. Father Mother Brother Sister _Grandparents Drugs Please check all the drugs you are now using or have used in the past: Amphetamines (Meth, diet pills..) presently using used in past dependency Barbiturates (downers, etc.) Cocaine or Crack Hallucinogenics (LSD, Mushrooms) Inhalants (glue, nitrous oxide) Marijuana Opiate narcotics (heroin, Oxycontin, Percoset, etc) PCP (angel dust) Club Drugs (Ketamine, Escasy, GHB, bath salts ) Please list all other drugs used
7 Social History Marital History Current marital status: Married Single Divorced Widowed Separated Living with partner Years married to current spouse/partner: years. Number of times married: times. Spouse/Partner s Name/Age Occupation Spouse/Partner s Health: Excellent Good Fair Poor Reason: Education Highest grade or degree earned How would you describe your usual performance: A & B B & C C & D D & F What was your best subject(s)? Weakest Were you ever held back to repeat a grade? Were you ever in any special classes/required special services? Occupations Current job title/length of employment Previous employment: At any time on a job, were you exposed to toxic, hazardous, noxious, or otherwise dangerous substances: Yes No Military History Branch: Discharge rank Type of discharge Years of service Military Duties: Major events (injury, exposure to chemicals, combat) Recreation Briefly list the types of recreational activities you enjoy Signature Date Thank you for completing this questionnaire to help improve your evaluation and treatment. Dr Armellino
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