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First Name:
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Last Name:
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Age:
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Date of Birth (mm/dd/yyyy):
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Gender:
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Gender other comment:
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Preferred pronoun:
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Preferred pronoun other comments:
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Currently pregnant or breastfeeding? (click on if yes):
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Allergies (click on if yes):
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Allergies and effect:
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Past medical history (please check all that apply):
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Past medical history comments:
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Currently on medication? (click on if yes):
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Current medications and regimen:
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Previously diagnosed with a psychiatric illness?(click on if yes)
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Previous psychiatric diagnosis:
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Have you been diagnosed with a learning disability? (click on if yes):
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What learning disability or disabilities?:
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Have you ever been diagnosed with ADD/ADHD? (Click on if yes):
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When were you diagnosed with ADD/ADHD?:
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What medication trials have you been on for ADD/ADHD?:
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Is ADD/ADHD still an issue for you currently?:
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What brings you here today?
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Emergency Contact (and their relationship to client):
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Who do you live with?:
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Other:
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Do you feel unsafe at home? (click on if yes):
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What makes you feel unsafe?:
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Do you have any children? (click if yes):
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How many children do you have, and how old are they?:
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Are you religiously affiliated? (click if yes):
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Religious Affiliation:
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Who are your social supports?:
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Social support comment:
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What is the highest level of education you have attained:
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Are you currently employed?:
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SLEEP
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On average how many hours do you sleep per night?:
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Do you have difficulties sleeping?
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Sleep Difficulties (Other):
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APPETITE:
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Do you have any diet restrictions?:
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How has your appetite been?
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On average how many meals do you consume daily?:
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Have you been losing weight without trying? (click on if yes):
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How much weight have you loss and in what timeframe?:
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Do you have a history of eating disorders? (click if yes):
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Eating disorder diagnosis and comments:
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ENERGY, DEPRESSION, AND ANXIETY:
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How would you rate your energy level on an average day?:
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How would you rate your depression over the past month on average 0-10, 10 being the worst
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How would you rate your anxiety over the past month on average 0-10, 10 being the worst
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How would you rate your stress over the past month on average 0-10, 10 being the worst
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Somatic complaints related to your anxiety/ depression?:
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Other somatic complaints due to anxiety/depression:
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History of panic attacks? (click on if yes):
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Frequency of panic attacks:
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Are there any other stressors in your life? (ex. court cases, family illness, etc.):
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SUBSTANCE USE:
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Do you use any health supplements? (click on if yes):
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What do you use? and how much?
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Do you drink caffeinated beverages? (click on if yes):
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On average, how many do you consume daily?:
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Do you use cannabis products? (click on if yes):
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On average, how much do you consume daily/weekly?:
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Do you use tobacco products? (click on if yes):
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On average, how much do you consume daily?:
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Do you drink alcoholic beverages? (click on if yes):
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On average, how many do you consume daily/ weekly/ monthly?:
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Do you use any other recreational substance use (including non-prescribed prescription medicine)?:
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What do you take, and how much?
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TRAUMA:
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Do you have a past history of trauma or abuse?
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Abuse/ trauma comments:
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FAMILY HISTORY:
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Do you have paternal family history of mental health or substance abuse history?:
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Paternal family mental health/ substance use history comments:
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Do you have maternal family history of mental health or substance abuse history?:
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Maternal family mental health/ substance use history comments:
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MENTAL STATUS EXAM:
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Appearance:
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Clothing:
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Eye Contact:
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Build:
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Posture:
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Body Movement:
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Behavior:
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Speech:
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Mood:
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Affect:
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Facial Expression:
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Perception:
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Hallucinations:
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Thought Content:
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Self Abuse Thoughts:
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Self abuse thoughts comments:
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Suicidal Thoughts:
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Suicidal thoughts comment:
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Aggressive Thoughts:
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Thought Process:
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Intellectual Functioning:
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Intelligence Estimate:
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Orientation:
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Memory:
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History of self injurious behavior or physical violence?:
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History of self injurious behavior or physical violence comments?:
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Is there anything you would like us to know prior to your appointment?:
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Other notes:
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PATIENT CONSENTS:
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Client consents to the following tests:
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Client consents to the following treatments:
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PLAN AND FOLLOW UP:
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Current plan for client:
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Client's follow up is scheduled for:
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