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Please read the following before you start filling out this form:
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This practice provides outpatient services only, we do not provide substance use services/treatment, nursing, social work
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case management, or intensive outpatient services. The practice does not treat medical disorders, schizophrenia, bipolar
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disorders, ADHD, psychosis, eating disorders, autism, or impulse control disorders. The practice treats adults only. Patients
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who need more intense or structured services (e.g., intensive outpatient, day program, social work, case management,
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group therapy, etc.) are advised to contact practices that offer such services. The practice does not prescribe or manage
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(adjust or provide detox) controlled substances (e.g., benzodiazepines, stimulants, opioid medications, etc.), and thus cannot
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accept patients who are currently taking or seeking controlled substances.
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The patient is advised to seek a provider who prescribes and manages controlled substances.
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Reason for Seeking Mental Health Services (Put "N/A" if none)
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Have you ever received or are currently receiving treatment for Mental Health Issues?
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1. Clinic Name
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1. Dates Treated: From (Month and Year) to (Month and Year)
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Treated By:
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2. Clinic Name
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2. Dates Treated: From (Month and Year) to (Month and Year)
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Treated By:
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3. Clinic Name
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3. Dates Treated: From (Month and Year) to (Month and Year)
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Treated By:
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Additional Clinic Name Fields
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4. Clinic Name
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4. Dates Treated: From (Month and Year) to (Month and Year)
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Treated By:
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5. Clinic Name
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5. Dates Treated: From (Month and Year) to (Month and Year)
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Treated By:
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6. Clinic Name
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6. Dates Treated: From (Month and Year) to (Month and Year)
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Treated By:
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Please List Current and Past Mental Health Diagnoses: (Put "N/A" if none)
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Have you ever taken or are currently taking Psychiatric Medications?
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1. Name of Medication
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Dosage and Frequency (e.g., 20mg, once daily)
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Effectiveness:
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Side Effects
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Duration Taken
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2. Name of Medication
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Dosage and Frequency (e.g., 20mg, once daily)
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Effectiveness:
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Side Effects
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Duration Taken
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3. Name of Medication
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Dosage and Frequency (e.g., 20mg, once daily)
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Effectiveness:
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Side Effects
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Duration Taken
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4. Name of Medication
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Dosage and Frequency (e.g., 20mg, once daily)
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Effectiveness:
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Side Effects
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Duration Taken
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5. Name of Medication
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Dosage and Frequency (e.g., 20mg, once daily)
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Effectiveness:
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Side Effects
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Duration Taken
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Additional Psychiatric Medication Fields
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6. Name of Medication
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Dosage and Frequency (e.g., 20mg, once daily)
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Effectiveness:
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Side Effects
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Duration Taken
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7. Name of Medication
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Dosage and Frequency (e.g., 20mg, once daily)
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Effectiveness:
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Side Effects
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Duration Taken
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8. Name of Medication
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Dosage and Frequency (e.g., 20mg, once daily)
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Effectiveness:
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Side Effects
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Duration Taken
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Please List All other prescription medication: (Put "N/A" if none)
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Please List All Over-The-Counter Medications and Supplements: (Put "N/A" if none)
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Current Pharmacy
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Name of Pharmacy (Put "N/A" if none)
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Address:
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Phone number:
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Do you have Past Psychiatric Hospitalizations
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1. Hospital Name:
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Hospital Location
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Date Admitted
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Reason for Admission
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2. Hospital Name:
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Hospital Location
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Date Admitted
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Reason for Admission
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Additional Past Psychiatric Hospitalizations Field
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3. Hospital Name:
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Hospital Location
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Date Admitted
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Reason for Admission
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4. Hospital Name:
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Hospital Location
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Date Admitted
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Reason for Admission
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Past and Current Medical History
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Date of Last Physical
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Height
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Current weight
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Have you recently gained weight?
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Have you recently lost weight?
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Amount of Weight Gained/Lost (kg/lbs)
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Changes in Energy Levels
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Sleep Difficulties
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Other sleep difficulties (Put "N/A" if none)
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Caffeine use (coffee, tea, colas, energy drinks): (place "NA" if not applicable)
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Please indicate and specify any medical conditions/issues/diagnoses in the following body systems.
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Eyes
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Other Eye Conditions:
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Do you use corrective lenses?
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Ear/Nose/Throat:
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Other Ear/Nose/Throat Conditions:
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Oral/Dental:
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Other Oral/Dental Conditions:
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Respiratory
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Other Respiratory Conditions:
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Cardiac/Heart:
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Other Cardiac/Heart Conditions:
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Gastrointestinal
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Other Gastrointestinal Conditions:
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Bowel/Bladder:
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Other Bowel/Bladder Conditions:
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Reproductive
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Other Reproductive Conditions:
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Liver
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Other Liver Conditions:
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Kidney
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Other Kidney Conditions:
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Endocrine/Hormonal:
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Other Endocrine/Hormonal Conditions:
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Hematological/Blood:
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Other Hematological/Blood Conditions:
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Dermatological/Skin
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Other Dermatological/Skin Conditions:
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Musculoskeletal
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Other Musculoskeletal Conditions:
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Neurological
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Other Neurological Conditions:
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Autoimmune Conditions:
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Cancer: (Specify Type/Area of Cancer)
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Head Injuries:
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Surgical Procedures:
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Other Conditions:
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Do you have a current or past history of any of the following conditions?
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For Female Patients
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Are you capable of becoming pregnant?
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Are you currently pregnant?
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Do you have any signs or symptoms of being pregnant?
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Are you currently planning for pregnancy?
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Date and result of most recent pregnancy test (if applicable)?
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Currently using contraception (please list type)?
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History of pregnancies (number and any complications/miscarriages)
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Menstrual Cycle
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CURRENT PRIMARY CARE PROVIDER OR MEDICAL SPECIALIST: (Type N/A if not applicable)
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Clinic name:
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Clinic phone number:
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Clinic fax number:
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Clinic address:
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Provider name:
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Date of most recent lab work:
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Approximate date of last physical:
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Allergies
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No Known Allergies
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Are you allergic to any drugs?
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Drug Allergies (Please indicate Drug and Type of Reaction (e.g., hives, swelling))
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Do you have any food allergies?
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Food Allergies (Please indicate specific food and Type of Reaction (e.g., hives, swelling))
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Do you have any known Environmental Allergy?
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Environmental Allergies (Please indicate allergen and Type of Reaction (e.g., hives, swelling))
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Do you have any other Allergies?
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Other Allergies (Please indicate allergen and Type of Reaction (e.g., hives, swelling))
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Family History
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Has anyone in your family been diagnosed with or treated for any of the following:
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Thyroid Disease
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Number of Family Members diagnosed with or treated for this condition:
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Diabetes
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Number of Family Members diagnosed with or treated for this condition:
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Cancer
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Number of Family Members diagnosed with or treated for this condition:
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Hypertension
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Number of Family Members diagnosed with or treated for this condition:
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Respiratory Disease/Conditions
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Number of Family Members diagnosed with or treated for this condition:
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Cardiac/Heart Disease
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Number of Family Members diagnosed with or treated for this condition:
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High Cholesterol
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Number of Family Members diagnosed with or treated for this condition:
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Liver Disease
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Number of Family Members diagnosed with or treated for this condition:
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Seizure Disorder
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Number of Family Members diagnosed with or treated for this condition:
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Gastrointestinal Disease
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Number of Family Members diagnosed with or treated for this condition:
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Blood Disorders
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Number of Family Members diagnosed with or treated for this condition:
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Autoimmune Disease
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Number of Family Members diagnosed with or treated for this condition:
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Violence
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Number of Family Members diagnosed with or treated for this condition:
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Autism
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Number of Family Members diagnosed with or treated for this condition:
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Other (please specify):
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Physical Activity
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Do you exercise regularly?
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How many days a week do you exercise? (Indicate N/A if not applicable)
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How much time each day do you exercise? (Indicate N/A if not applicable)
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What type(s) of exercise do you do? (Indicate N/A if not applicable)
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Past psychiatric/mental health family history:
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Has anyone in your family been diagnosed with or treated for:
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Bipolar disorder
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Number of Family Members diagnosed with or treated for this condition:
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Schizophrenia
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Number of Family Members diagnosed with or treated for this condition:
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Depression
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Number of Family Members diagnosed with or treated for this condition:
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Post-traumatic stress
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Number of Family Members diagnosed with or treated for this condition:
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Anxiety
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Number of Family Members diagnosed with or treated for this condition:
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Cancer
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Number of Family Members diagnosed with or treated for this condition:
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Obsessive-compulsive disorder (OCD)
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Number of Family Members diagnosed with or treated for this condition:
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Panic Attacks
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Number of Family Members diagnosed with or treated for this condition:
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Alcohol abuse
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Number of Family Members diagnosed with or treated for this condition:
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Other substance abuse
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Number of Family Members diagnosed with or treated for this condition:
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Anger
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Number of Family Members diagnosed with or treated for this condition:
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Suicide
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Number of Family Members diagnosed with or treated for this condition:
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Violence
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Number of Family Members diagnosed with or treated for this condition:
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Autism
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Number of Family Members diagnosed with or treated for this condition:
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Other (please specify):
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Has any family member been treated with a psychiatric medication?
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If yes, who was treated, what medications did they take, and how effective was the treatment? (Type N/A if not applicable)
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Are you a survivor of:
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Physical violence/ physical abuse
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Sexual abuse/assault
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Emotional/verbal abuse
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Exposure to other traumatic events
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Do you use any form of tobacco?
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Forms of Tobacco
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Other forms of tobacco (Please indicate)
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How much do you smoke per day?
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Do you want to stop?
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SUBSTANCE USE/ABUSE HISTORY:
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Alcohol
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Frequency:
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Tobacco
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Frequency:
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Cannabis
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Frequency:
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Benzodiazepines
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Frequency:
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Cocaine
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Frequency:
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Methamphetamine/other stimulants
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Frequency:
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Opioids
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Frequency:
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Hallucinogens
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Frequency:
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Prescription medications
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Frequency:
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Over the counter (OTC) medications
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Frequency:
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Other (please specify):
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History of substance abuse treatment:
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Motivation for reduction or cessation?
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Educational History:
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Highest Grade Completed?
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Type and name of school?
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Did you attend college?
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Name of College?
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Major?
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What is your highest educational level or degree attained?
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Occupational History:
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Are you currently:
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How long in present position?
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What is/was your occupation?
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Where do you work?
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Have you ever served in the military?
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If yes, what branch and when?
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Honorable discharge
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Other (please specify):
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Relationship History and Current Family:
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Are you currently:
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How long?
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If not married, are you currently in a relationship?
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If yes, How long?
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Are you sexually active?
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How would you identify your sexual orientation?
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What is your spouse or significant other's occupation?
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Describe your relationship with your spouse or significant other:
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Have you had any prior marriages?
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If yes, How many?
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How long?
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Do you have children?
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If yes, list ages and gender:
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Describe your relationship with your children:
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List everyone who currently lives with you:
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Religious/Spiritual affiliation
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Current or past legal issues
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*Completion and submission of this form does not constitute a clinical relationship, admission for services, or establishment of
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a patient-provider relationship. This form is for informational purposes and may not be reviewed within 72 hours. If you are
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experiencing unmanageable symptoms, suicidal thoughts, safety concerns, and/or a psychiatric/medical emergency, please dial 911
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or present to the nearest emergency room. If you are admitted to services, this form may become part of your medical record.
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Confirmation of Agreement:
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Your Full Name and Date
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