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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?

onpatient Additional Info (Duplicate) Medical Form

Psychiatrist

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Published: Nov. 19, 2020, 1:49 p.m.
Doctor: Dr. History Physical
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