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Please check one of the following:
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NEW PATIENT
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EXISTING PATIENT
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NEW PATIENT INTAKE
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Where did you find us?
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Who referred you?
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Reason for seeking care:
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PSYCHIATRIC HISTORY
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Past Psychiatric History (diagnoses)
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Previous Psychiatrist Name & Contact (If applicable)
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Therapist Name & Contact (If applicable)
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Have you ever tried any of these medications in the past?
• • •
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MEDICAL HISTORY
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Past Medical History
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Past Surgical History
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Primary Care Provider (PCP) Name & Contact
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OTHER
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Current Medication List (Including Psychotropics, Medical, & Over the Counter)
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Allergies
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Height
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Weight
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Pharmacy Information
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Please note any updates since last visit (example: pharmacy, medication, or health changes)
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Comments/Concerns
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Screening Tools
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Depression Assessment
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Over the last 2 weeks, how often have you been bothered by
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1. Little interest or pleasure doing things
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2. Feeling down / depressed / hopeless
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3. Trouble falling or staying asleep, or sleeping too much
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4. Feeling tired and having little energy
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5. Poor appetite or over eating
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6. Feeling bad about yourself/feeling a failure/feeling you have let people down:
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7. Trouble concentrating on things, such as reading the newspaper/watching television
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8. Moving/Speaking so slow that other people could have noticed/the opposite
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9. Thoughts that you would be better off dead or of hurting yourself in someway
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If Yes, Explain:
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Depression Score
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Comments
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Anxiety Assessment
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Over the last 2 weeks, how often have you been bothered by the following problems?
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1. Feeling nervous, anxious or on edge
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2. Not being able to stop or control worrying
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3. Worrying too much about different things
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4. Trouble relaxing
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5. Being so restless that it is hard to sit still
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6. Becoming easily annoyed or irritable
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7. Feeling afraid as if something awful might happen
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Anxiety Score
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Comments
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Alcohol Misuse Assessment
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1. Ever felt the need to cut down on drinking/drug use?
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2. Have people annoyed you by criticizing your drinking or drug use?
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3. Have you felt bad or guilty about your drinking or drug use?
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4. Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover?
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Risk Score
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Comments
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