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Primary Care Physician
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Current Psychiatrist
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Current Therapist/Counselor
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What is (are) the problem(s) for which you are seeking help?
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Current Symptoms
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If Other, specify
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Have you ever had feelings or thoughts that you didn't want to live?
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Do you currently feel that you don't want to live?
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How often do you have these thoughts?
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When was the last time you had suicidal thoughts?
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Do you have a plan for how you would kill yourself?
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Do you have access to guns? If yes, please explain.
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Past Medical History
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Allergies
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Weight & Height
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List ALL current prescription medications (Medication Name, Total Daily Dosage and Estimated Start Date)
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Current over-the-counter medications or supplements
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Current medical problems:
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Past medical problems, nonpsychiatric hospitalization, or surgeries
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Do you have any concerns about your physical health that you would like to discuss?
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Have you ever had an EKG?
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If yes, when?
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For women only
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Date of last menstrual period
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Are you currently pregnant or do you think you might be pregnant?
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Are you planning to get pregnant in the near future?
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Birth control method
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Medical Review of Systems:
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Specify:
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Family Medical History
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Specify:
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When your mother was pregnant with you, were there any complications during the pregnancy or birth?
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Past Psychiatric History
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Have you ever seen a psychiatrist or therapist?
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If yes, Reason, Dates Treated, By Whom
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Have you ever been in a Psychiatric Hospital?
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If yes, Reason, Dates Hospitalized, Where
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Have you ever attempted suicide?
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Suicide Attempts:
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Antidepressant Trials:
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Supplements for Mood:
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Mood Stabilizers:
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Antipsychotics
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Sedative-Hypnotics
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ADHD Medications
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Other Psychotropic Medications:
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Your Exercise Level
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Do you exercise regularly?
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How many days a week do you get exercise?
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How much time each day do you exercise?
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What kind of exercise do you do?
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Family Psychiatric 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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Schizophrenia
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Depression
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Post-traumatic stress
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Anxiety
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Alcohol abuse
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Anger
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Other substance abuse
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Suicide
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Violence
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If yes, who had each problem?
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Has any family member been treated with psychiatric medication?
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If yes, who was treated, what medications did they take, and how effective was the treatment?
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Substance Use
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Have you ever been treated for alcohol or drug use or abuse?
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If yes, for which substances?
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If yes, where were you treated and when?
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How many days per week do you drink any alcohol?
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What is the least number of drinks you will drink in a day?
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What is the most number of drinks you will drink in a day?
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In the past three months, what is the largest number of alcoholic drinks you have consumed in one day?
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Have you ever felt you ought to cut down on your drinking or drug use?
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Have people annoyed you by criticizing your drinking or drug use?
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Have you ever felt bad or guilty about your drinking or drug use?
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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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Do you think you may have a problem with alcohol or drug use?
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Have you used any street drugs in the past 3 months?
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If yes, which ones?
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Have you ever abused prescription medication?
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If yes, which ones and for how long?
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Have you ever tried the following?
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Methamphetamine
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If yes, how long and when did you last use it?
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Cocaine
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If yes, how long and when did you last use it?
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Stimulants (pills)
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If yes, how long and when did you last use it?
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Heroin
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If yes, how long and when did you last use it?
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LSD or Hallucinogens
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If yes, how long and when did you last use it?
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Marijuana
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If yes, how long and when did you last use it?
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Methadone
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If yes, how long and when did you last use it?
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Tranquilizer/sleeping pills
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If yes, how long and when did you last use it?
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Ecstasy
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If yes, how long and when did you last use it?
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Other
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How many caffeinated beverages do you drink a day?
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Coffee
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Sodas
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Tea
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Tobacco History
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Have you ever smoked cigarettes?
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Currently?
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How many packs per day on average?
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How many years?
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In the past?
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How many years did you smoke?
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When did you quit?
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Pipe, cigars, or chewing tobacco
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Currently
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In the past?
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What kind?
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How often per day on average?
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How many years?
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Family Background and Childhood History
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Were you adopted?
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Where did you grow up?
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List your siblings and their ages
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What was your father's occupation?
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What was your mother's occupation?
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Did your parents’ divorce?
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If so, how old were you when they divorced?
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If your parents divorced, who did you live with?
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Describe your father and your relationship with him
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Describe your mother and your relationship with her
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How old were you when you left home?
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Has anyone in your immediate family died?
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Who and when?
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Trauma History
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Do you have a history of being abused emotionally, sexually, physically or by neglect?
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Please describe when, where and by whom:
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Educational History
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Highest Grade Completed?
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Where?
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Did you attend college?
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Where?
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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 so, what branch and when?
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Honorable discharge
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If No, 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 so, 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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Legal History
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Have you ever been arrested?
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Do you have any pending legal problems?
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Spiritual Life
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Do you belong to a particular religion or spiritual group?
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If yes, what is the level of your involvement?
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Do you find your involvement helpful during this illness, or does the involvement make things more difficult or stressful for yo
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Is there anything else that you would like me to know?
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