|
Where did you find us?
|
Which specialists do you see?
• • •
|
|
Who referred you?
|
Do you use online scheduling?
|
|
Want access to online portal?
|
Anything special we need to know
|
|
|
|
|
New Patient Intake
|
|
|
Refereed By
|
Primary Care Physician
|
|
ABOUT YOUR CURRENT PROBLEMS
|
|
|
List The Problems of Greatest Concern to You
|
|
|
Describe The Problems in Your Own Words
|
|
|
Prior Psychiatric, Psychological, or Chemical Dependency Services
|
|
|
1. Inpatient/ Outpatient
|
Practitioner Seen
|
|
Date of Service
|
Were Services Helpful?
|
|
2. Inpatient/ Outpatient
|
Practitioner Seen
|
|
Date of Service
|
Were Services Helpful?
|
|
3. Inpatient/ Outpatient
|
Practitioner Seen
|
|
Date of Service
|
Were Services Helpful?
|
|
4. Inpatient/ Outpatient
|
Practitioner Seen
|
|
Date of Service
|
Were Services Helpful?
|
|
SUBSTANCE ABUSE HISTORY
|
|
|
Have you ever felt you should cut down on your drinking/drug use?
|
|
|
Have people annoyed you by criticizing your drinking/drug use?
|
|
|
Have you ever felt bad or guilty about your drinking/drug use?
|
|
|
Have you ever drank/used drugs in the morning to steady your nerves or relieve a hangover?
|
|
|
FAMILY MEDICAL, PSYCHIATRIC & CHEMICAL DEPENDENCY HISTORY
|
|
|
Nervous Problems (Anxiety)
• • •
|
Other please specify
|
|
Depression
• • •
|
Other please specify
|
|
Psychiatric Treatment
• • •
|
Other please specify
|
|
Drinking Problems
• • •
|
Other please specify
|
|
Medical Conditions
• • •
|
Other please specify
|
|
Drug Abuse
• • •
|
Other please specify
|
|
Medical Treatment
• • •
|
Other please specify
|
|
Other please specify
|
|
|
Have you had a problem/diagnostic/treatment procedure regarding any of the following?
• • •
|
|
|
Other please specify
|
|
|
Adverse/ allergic drug reactions
|
|
|
Current/ recent medications
|
|
|
1. Name
|
Dose
|
|
Frequency
|
Start
|
|
Stop
|
|
|
2. Name
|
Dose
|
|
Frequency
|
Start
|
|
Stop
|
|
|
3. Name
|
Dose
|
|
Frequency
|
Start
|
|
Stop
|
|
|
Alternative medications/ vitamins
|
Highest weight
|
|
Number of pregnancies
|
Regular menstrual periods
|
|
RELATIONSHIP HISTORY
|
|
|
Place of birth
|
|
|
Family data: Father
|
|
|
Living
|
Age if living
|
|
Occupation
|
Health Status
|
|
If deceased, cause of death
|
Frequency & nature of contact
|
|
Family data: Mother
|
|
|
Living
|
Age if living
|
|
Occupation
|
Health Status
|
|
If deceased, cause of death
|
Frequency & nature of contact
|
|
Family data: Brothers & Sisters
|
|
|
1. Name
|
Sex
|
|
Age
|
Residing in
|
|
2. Name
|
Sex
|
|
Age
|
Residing in
|
|
3. Name
|
Sex
|
|
Age
|
Residing in
|
|
4. Name
|
Sex
|
|
Age
|
Residing in
|
|
Did you live with anyone other than your natural parents for any significant amount of time during your childhood years?
|
|
|
Marital Status
|
|
|
If married, re married or partnered, for how long?
|
|
|
If devoiced, separated, or widowed, for how long?
|
|
|
If previously married or in a long-term relationship, when?
|
|
|
Spouse/ partners age
|
Spouse/ partners occupation
|
|
Spouse/ partners prior marriages (specify when and how long)
|
|
|
Family data: Children/ stepchildren
|
|
|
1. Name
|
Sex
|
|
Age
|
Residing in
|
|
2. Name
|
Sex
|
|
Age
|
Residing in
|
|
3. Name
|
Sex
|
|
Age
|
Residing in
|
|
4. Name
|
Sex
|
|
Age
|
Residing in
|
|
LIVING ARRANGEMENTS/HOME ENVIRONMENTS
|
|
|
With whom do you currently live?
|
|
|
Did you receive any special educational services?
|
|
|
EDUCATION
|
|
|
Highest level of education completed
|
|
|
Did you receive any special educational services?
|
|
|
OCCUPATIONAL HISTORY
|
|
|
Occupation
|
Current position held
|
|
If not currently working, what was the date you last worked?
|
|
|
Past work history
|
|
|
1. Position
|
Employer
|
|
Years worked
|
|
|
2. Position
|
Employer
|
|
Years worked
|
|
|
3. Position
|
Employer
|
|
Years worked
|
|
|
PATIENT HEALTH QUESTIONNAIRE
|
|
|
Over the last 2 weeks, how often have you been bothered
|
|
|
by any of the following problems?
|
|
|
1: Little interest or pleasure in doing things
|
2: Feeling down, depressed or hopeless
|
|
3: Trouble falling or staying asleep, or sleeping too much
|
|
|
4: Feeling tired or having little energy
|
5:Poor appetite or over eating
|
|
6: Feeling bad about yourself - or that you are a failure or have let yourself or your family down
|
|
|
7: Trouble concentrating on things, such as reading the newspaper or watching television
|
|
|
8: Moving or speaking so slowly that other people could have noticed? Or the opposite – being so fidgety or restless that you ha
|
|
|
9: Thoughts that you would be better off dead or of hurting yourself in some way
|
|
|
Total Score
|
|
|
If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home,
|
|
|
MOOD DISORDER QUESTIONNAIRE
|
|
|
1: Has there ever been a period of time when you were not your usual self and...
|
|
|
you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trou
|
|
|
you were so irritable that you shouted at people or started fights or arguments?
|
|
|
you felt much more self-confident than usual?
|
|
|
You got much less sleep than usual and found you didn’t really miss it?
|
|
|
thoughts raced through your head or you couldn’t slow your mind down?
|
|
|
you were so easily distracted by things around you that you had trouble concentrating or staying on track?
|
|
|
you had much more energy than usual?
|
|
|
you were much more active or did many more things than usual?
|
|
|
you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?
|
|
|
you were much more interested in sex than usual?
|
|
|
you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?
|
|
|
spending money got you or your family in trouble?
|
|
|
2: If you checked YES to more than one of the above, have several of these ever happened during the same period of time?
|
|
|
3: How much of a problem did any of these cause you–like being unable to work; having family, money or legal troubles, getting i
|
|
|
THE GENERALIZED ANXIETY DISORDER 7 - ITEM SCALE
|
|
|
Over the last 2 weeks, how often have you been bothered by any of the following problems?
|
|
|
1: Feeling nervous, anxious, or on edge
|
2: Not being able to stop or control worrying
|
|
3: Worrying too much about different things
|
4: Trouble relaxing
|
|
5:Being so restless that it is hard to sit still
|
6: Becoming easily annoyed or irritable
|
|
7: Trouble concentrating on
|
Total score
|
|
If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home,
|
|
|
ADULT ADHD SELF - REPORT SCALE (ARS - V1 .1) SYMPTOM CHECKLIST
|
|
|
Part A
|
|
|
1:How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?
|
|
|
2:How often do you have difficulty getting things in order when you have to do a task that requires organization?
|
|
|
3:How often do you have problems remembering appointments or obligations?
|
|
|
4: When you have a task that requires a lot of thought, how often do you avoid or delay getting started?
|
|
|
5: How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?
|
|
|
6: How often do you feel overly active and compelled to do things, like you were driven by a motor?
|
|
|
Part B
|
|
|
7: How often do you make careless mistakes when you have to work on a boring or difficult project?
|
|
|
8: How often do you have difficulty keeping your attention when you are doing boring or repetitive work?
|
|
|
9: How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?
|
|
|
10: How often do you misplace or have difficulty finding things at home or work?
|
|
|
11: How often are you distracted by activity or noise around you?
|
|
|
12: How often do you leave your seat in meetings or other situations in which you are expected to remain seated?
|
|
|
13: How often do you feel restless or fidgety?
|
|
|
14: How often do you have difficulty unwinding and relaxing when you have time to yourself?
|
|
|
15: How often do you find yourself talking too much when you are in social situations?
|
|
|
16: When you’re in a conversation, how often do you find yourself finishing the sentences of the people you are talking to, befo
|
|
|
17: How often do you have difficulty waiting your turn in situations when turn taking is required?
|
|
|
18: How often do you interrupt others when they are busy?
|
|
