|
Check below if you are a new or returning client
|
|
|
New Client
|
Returning Client
|
|
New Client Information
|
|
|
What's your preferred name?
|
What are your preferred pronouns?
|
|
Check here if you are currently taking prescription medications.
|
|
|
What are the medications, doses and directions (ex: amlodipine 10mg once a day)
|
|
|
Check here if you are currently taking over the counter medications regularly.
|
|
|
What are the medications, how much and how often (ex: Claritin (loratidine) 10mg one a day )
|
|
|
Check here if you are currently taking supplements regularly.
|
|
|
What are the supplements, doses and how often you take them (ex: Vitamin B12 1000mcg daily)
|
|
|
List any medication allergies and reactions (ex: sulfa drugs- hives)
|
|
|
List any psychiatric medications that you've tried in the past and how it's worked (or not) (ex: Zoloft- nightmares)
|
|
|
Check here if you have a primary care practitioner.
|
|
|
Who is your PCP and/or what practice are they with? (ex: Mary Smith at Boulder Family Medicine)
|
What is their phone number, email or website?
|
|
Check here if you have a therapist that you talk to regularly.
|
|
|
Who your therapist and/or what practice are they with? (ex: John William with Healing Therapy)
|
What is their phone number, email, or website?
|
|
Returning Client Updates
|
|
|
Check here if there are updates to your medications or supplements.
|
|
|
What has changed for your medications?
|
|
|
Check here if there are updates to your name and pronoun preferences.
|
|
|
What is your preferred name and/or pronouns?
|
|
|
Check here if there any other updates you want to tell us about.
|
|
|
Tell us your update here
|
|
|
|
|
|
Check here if you have been struggling with depression
|
|
|
Indicate your answer to the frequency of the comments below considering how you have felt over the last 2 weeks
|
|
|
I feel little interest or pleasure in doing things
|
I feel down, depressed, or hopeless.
|
|
I have trouble falling asleep, staying asleep, or sleeping too much.
|
I feel tired or have little energy
|
|
My appetite has change so that now I eat too little or too much.
|
I feel bad about myself or that I'm a failure of have let my family down
|
|
I have trouble concentrating on things ushc as reading the newspaper or watching television.
|
I have been moving or speaking so slowely that other people could have noticed OR I've been fidgety, restless
|
|
I think that I would be better off dead or hurting myself.
|
How difficult have these problems made it to work, take care of things at home or get along with people?
|
|
Check here if you have been struggling with anxiety.
|
|
|
Indicate your answer to the frequency of the comments below considering how you have felt over the last 2 weeks
|
|
|
I feel nervous, anxious, or on edge.
|
I'm not able to stop or control worrying
|
|
I worry too much about different things.
|
I have trouble relaxing
|
|
I feel so restless that it's hard to sit still.
|
I easily become annoyed or irritable.
|
|
Check here if you have been diagnosed with or think you might have bipolar
|
|
|
Answer the questions below that best apply to you
|
|
|
1. Has there ever been a period of time when you were not your usual self and (select all that apply)
• • •
|
|
|
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 able to work; having family, money, or legal issues or fights?
|
