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New patients, please complete this section.
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In a few sentences, please tell me what is
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bothering you and how long this problem
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has been going on.
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Was there a recent change or situation that
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convinced you to make this appointment?
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I have received mental health care before
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Mental Health Treatment History
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Have you ever seen a (choose the following)
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If so, when was the first time?
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Check if you are currently seeing one:
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Name/type of provider
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Since when?
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How often?
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City/State
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Phone/Fax
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Is it helpful?
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Previous or other current mental health providers
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Name/type of provider
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Since when?
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How often?
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City/State
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Phone/Fax
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Is/was it helpful?
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Name/type of provider
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Since when?
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How often?
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City/State
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Phone/Fax
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Is it helpful?
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Is it okay if I contact these people?
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List any concerns with me contacting them:
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Check if you have you ever:
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Considered or attempted suicide?
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When? How?
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Been hospitalized psychiatrically
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When, where and why?
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been evaluated for involuntary admission
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Describe circumstances, etc
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had violent behavior toward another person?
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Describe circumstances, etc.
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Psychiatric Medication History
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Have you taken prior Psychiatric Medications?
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Have you ever taken any of these medications?
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Dates taken (approx)
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What did it help with?
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Side effects?
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Comments
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Have you ever taken any of these medications?
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Dates taken (approx)
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What did it help with?
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Side effects?
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Comments
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Have you ever taken any of these medications?
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Dates taken (approx)
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What did it help with?
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Side effects?
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Comments
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Have you ever taken any of these medications?
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Dates taken (approx)
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What did it help with?
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Side effects?
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Comments
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Have you ever taken any of these medications?
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Dates taken (approx)
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What did it help with?
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Side effects?
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Comments
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Have you ever taken any of these medications?
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Dates taken (approx)
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What did it help with?
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Side effects?
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Comments
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Have you taken any of these?
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Dates taken (approx)
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What did it help with?
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Side effects?
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Comments
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Have you taken any of these medications?
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Dates taken (approx)
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What did it help with?
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Side effects?
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Comments
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Medical History
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Please list any major medical events, hospitalizations, surgeries, seizures, etc
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Have you or anyone blood related to you ever been diagnosed/treated for any of the following
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ADD/ADHD
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Self/Parent, sibling, child/Extended Family
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Anger Issues
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Self/Parent, sibling, child/Extended Family
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Anxiety
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Self/Parent, sibling, child/Extended Family
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Bipolar Disorder
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Self/Parent, sibling, child/Extended Family
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Depression
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Self/Parent, sibling, child/Extended Family
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Eating Disorder
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Self/Parent, sibling, child/Extended Family
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Phobias
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Self/Parent, sibling, child/Extended Family
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Personality Disorder
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Self/Parent, sibling, child/Extended Family
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Schizophrenia or Psychotic Disorder
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Self/Parent, sibling, child/Extended Family
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Trauma/PTSD
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Self/Parent, sibling, child/Extended Family
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Inpatient treatment
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Self/Parent, sibling, child/Extended Family
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Substance Abuse/Addiction
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Self/Parent, sibling, child/Extended Family
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Suicide/Self-Harming Behaviors
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Self/Parent, sibling, child/Extended Family
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OCD
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Self/Parent, sibling, child/Extended Family
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Dementia
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Self/Parent, sibling, child/Extended Family
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Diabetes
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Self/Parent, sibling, child/Extended Family
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Cancer
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Self/Parent, sibling, child/Extended Family
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Cardiac rhythm problems
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Self/Parent, sibling, child/Extended Family
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Stroke
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Self/Parent, sibling, child/Extended Family
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Kidney Problems
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Self/Parent, sibling, child/Extended Family
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Liver Problems
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Self/Parent, sibling, child/Extended Family
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Thyroid Problems
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Self/Parent, sibling, child/Extended Family
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Heart problems
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Self/Parent, sibling, child/Extended Family
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Migraines
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Self/Parent, sibling, child/Extended Family
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Autoimmune diseases
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Self/Parent, sibling, child/Extended Family
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Bleeding disorders (sickle cell, etc.)
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Self/Parent, sibling, child/Extended Family
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Osteoporosis or other bone disease
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Self/Parent, sibling, child/Extended Family
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Chronic pain
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Self/Parent, sibling, child/Extended Family
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Seizure Disorder
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Self/Parent, sibling, child/Extended Family
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Other
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ARNP Comments
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Sexual Health
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Please indicate all the apply
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Type of contraception used:
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Additional information:
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Women:
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Do you experience problematic PMS?
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First day of last menstrual period
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Nursing, pregnant or planning to become pregnant
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Comments:
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Childhood History:
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To the best of your knowledge did you make
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all of your developmental milestones?
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Walked/talked on time, etc
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Where did you grow up?
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Who lived with you?
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What was your childhood like (happy/chaotic/etc)
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ARNP Comments
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Please describe your parents, siblings, and your relationships with them
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Parents
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and brief statement about your relationship
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Siblings
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and brief statement about your relationship
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ARNP Comments
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Educational History:
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Highest level of education you have achieved
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What are some of your strengths as a learner?
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What are some of your weaknesses as a learner?
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Mark all that apply about your education.
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Additional educational experience comments:
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Employment History
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Do you work outside the home?
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How many hours a week?
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How many years with this employer?
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What do you like/dislike about your job?
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ARNP Comments
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Social History:
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Please list at least 2 people that you feel you
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can count on if you are having a difficult time
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How would you describe your social way of being?
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(For example, introvert/extrovert, slow to warm
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up, outgoing, shy, prefer small/large groups)
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Social factors: Check all that apply.
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Persons living at home with you:
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Sleep, Exercise, and Self Care
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Do you have difficulty falling or staying asleep
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Average number of hours of sleep on work days?
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Average hours of sleep on days off?
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Do you wake up feeling refreshed?
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What do you do for exercise?
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How long? How often?
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Describe what you eat for:
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Breakfast, lunch, and dinner in a typical day.
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What do you snack on?
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What are some activities that help you feel:
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Peaceful, content, or relaxed?
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Thank You!
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