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New patients only:
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In a few sentences, please tell me what is bothering you, and how long it has been going on
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Was there a recent change or situation that convinced you to make this appointment?
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Mental Health History
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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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Acted violently toward another person?
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Describe circumstances, etc.
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I have seen a mental health professional in an office or clinic before
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None of the above apply to me.
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What type of provider(s) have you seen?
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When was the first time?
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Please list current/previous mental health providers, starting with the most recent.
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Name and contact information of provider:
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When did you start and stop seeing this person?
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Comments:
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Name and contact information of provider:
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When did you start and stop seeing this person?
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Comments
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Name and contact information of provider:
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When did you start and stop seeing this person?
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Comments
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Please describe any concerns you have about me contacting any of these providers.
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Psychiatric Medication History
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I have taken medication for mental health symptoms in the past.
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I have never taken any 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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Comments
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Personal and Family Medical History
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Please list any major medical events, hospitalizations, surgeries, seizures, etc that YOU have experienced.
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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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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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Depression
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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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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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ARNP Comments
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Sexual Health
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Please indicate all that apply
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Type of contraception used:
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Additional information:
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Questions for individuals Assigned Female At Birth:
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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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ARNP comments:
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Childhood History:
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How would you describe your childhood?
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As far as you know, did you meet childhood milestones on time (walking, talking, potty training, etc)?
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ARNP Comments
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Please describe your parents, siblings, and your relationships with them
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Parents
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Siblings
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ARNP Comments
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Educational History:
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Highest level of education you have achieved
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What are some of your strengths as a learner?
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What are some of your weaknesses as a learner?
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Mark all that apply about your education.
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Additional educational experience comments:
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Employment History
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Please tell me about your work (paid/volunteer/caregiving/etc)?)
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ARNP Comments
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Social Support:
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How would you describe your social way of being, (For example, introvert/extrovert, outgoing, shy, prefer small groups, etc:
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Tell me about your support network : Check all that apply.
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Which friends or family members do you feel you can can talk to about your mental health.
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People living at home with you:
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Spiritual Beliefs (All are welcome. This is strictly to help identify sources of support that may be relevant to you.)
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Self Care Behaviors:
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Tell me about your sleep, including any difficulty falling/staying asleep, hours of sleep most nights.
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What do you do for exercise? How often?
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What do you typically eat for breakfast, lunch and dinner? Snacks?
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What are some activities that help you feel peaceful, content, or relaxed?
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Thank You!
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