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Patient Information
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Who may you thank for sending you to our office?
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Other
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Which specialists do you see?
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Have you ever seen a (choose the following)
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Who referred you?
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Anything special we need to know
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Current Vocational/Employment
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Occupation
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Employer
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Marital Status
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Please indicate all the apply
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Type of contraception used:
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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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Spouse Information (If Applicable)
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Name:
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Home Phone
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Pharmacy Information
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Pharmacy Name
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Phone number / Fax number
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Emergency contact (if other than spouse)
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Name
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Relationship
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Telephone
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Are you currently pregnant
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Any Surgery?
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If yes, please mention surgery / date
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Past Medical History
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Other
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List all medications/herbs/vitamins
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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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Have you ever taken any of these medications?
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Have you ever taken any of these medications?
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Have you ever taken any of these medications?
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Have you ever taken any of these medications?
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Have you ever taken any of these medications?
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Have you taken any of these?
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Have you taken any of these medications?
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Allergies
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Other
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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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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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Feel sad
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Muscle aches
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Loss of interest
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Feel 'on edge'
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Feel hopeless
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Worrying too much
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Nothing is fun
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Impatient
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Weight loss
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Dry mouth
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Weight gain
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Bowel problems
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No energy
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Hyperventilation
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Cry easily
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Fainting/Dizziness
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Can't concentrate
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Pounding heart
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Can't fall asleep
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Trembling
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Sleep too much
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Sweating
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Guilt feelings
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Choking sensations
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Restless
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Nausea
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Irritable mood
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Numbness/Tingling
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Chest pain
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Waking up early
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Fear of dying
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Feel worse in the morning
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Fear of going crazy
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No need for sleep
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Can't pay attention
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Talking too much
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Can't finish what you want
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Racing thoughts
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Easily distracted
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Reckless driving
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Fidgeting
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Overactive sexually
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Interrupts others
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Uncontrollable urges
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Feeling numb
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Explosive temper
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Nightmares
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Gambling too much
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Flashbacks
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Drinking too much
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Startle response
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Sexually abused
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Feel Fear or Anxiety Of:
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Physically abused
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Buying/Spending Sprees
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Past Medical History
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Are you in good health at the present time
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Are you under a doctor's care at the present tim
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Are you taking any medication at the present time?
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Any Allergies to any medications?
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History of Constipation (difficulty in bowel mov
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History of frequent Headaches?
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Migraines?
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Do you smoke?
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Do you suffer from Allergies
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History of Heart Attack or Chest Pain?
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History of High Blood Pressure?
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History of Swelling Feet?
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History of Diabetes?
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History of Sleep Apnea
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Serious Injuries
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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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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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Educational History:
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Highest level of education you have achieved
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Mark all that apply about your education.
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Social factors: Check all that apply.
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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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and brief statement about your relationship
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Do you have difficulty falling or staying asleep
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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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Eating 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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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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Other family history
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Review of Systems
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Constitutional
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Head, Eyes, Ears, Nose and Throat
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Cardiovascular
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Hematologic / Lymphatic
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Hematologic / Lymphatic
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Respiratory
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Gastrointestinal
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Endocrine
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Musculoskeletal
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Nervous System
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Skin
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Allergic, Immunologic History
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Mental Health
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PHQ9 Depression Screening Form
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problems in the past two weeks:
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Loss of Interest?
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Feeling down, depressed or hopeless?
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Trouble Sleeping?
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Feeling tired or having little energy?
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Poor appetite or overeating?
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Feeling bad about oneself?
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Trouble Concentrating?
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Feeling slowed down or fidgety & restless?
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Wanting to die or self harm?
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Difficulty of these problems?
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PHQ9 Scoring
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Positive Depression Screen
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Negative Depression Screen
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ADHD Symptom Checklist
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Indicate which answer best describes how you have felt and conducted yourself over the past 6 MONTHS.
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How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?
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How often do you have difficulty getting things in order when you have to do a task that requires organization?
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How often do you have problems remembering appointments or obligations?
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When you have a task that requires a lot of thought, how often do you avoid or delay getting started?
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How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?
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How often do you feel overly active and compelled to do things, like you were driven by a motor?
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Part A Score
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How often do you make careless mistakes when you have to work on a boring or difficult project?
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How often do you have difficulty keeping your attention when you are doing boring or repetitive work?
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How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?
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How often do you misplace or have difficulty finding things at home or at work?
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How often are you distracted by activity or noise around you?
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How often do you leave your seat in meetings or other situations in which you are expected to remain seated?
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How often do you feel restless or fidgety?
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How often do you have difficulty unwinding and relaxing when you have time to yourself?
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How often do you find yourself talking too much when you are in social situations?
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How often do you find yourself finishing the sentences of the people you are talking to, before they can finish them themselves?
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How often do you have difficulty waiting your turn in situations when turn taking is required?
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How often do you interrupt others when they are busy?
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Part B Score
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InTouch Health can contact by the following methods
• • •
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