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Preferred Pharmacy
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Pharmacy Name:
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Complete address:
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Preferred Names and Pronouns
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Preferred Name [optional]
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Preferred Pronouns [optional]
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Reason for Visit
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Briefly describe the reasons for your visit today
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Medications
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Current Medications – list all medications you are currently taking
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Past Medications
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Allergies
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Do you have any allergies
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If yes, specify
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Psychiatric history
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Psychiatric diagnoses or symptoms
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Psychiatric hospitalizations (including PHP and IOP)
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Psychiatric ROS
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Depression: Sadness, hopelessness, guilt, low energy, crying, sleep changes, etc.
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If yes, specify
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Anxiety: Feeling on edge, worried, restless, irritable, panic attacks.
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If yes, specify
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Seasonal Depression: Depression symptoms in fall / winter.
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If yes, specify
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Suicidal thoughts, attempts or self-harm
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If yes, specify
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Social anxiety: Anxiety about social events, public speaking, etc.
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If yes, specify
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Mania or hypomania: Euphoric, impulsive, risky behavior, limited sleep
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If yes, specify
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Trauma / PTSD: Flashbacks, avoidance, hypervigilance, irritability, insomnia
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If yes, specify
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Obsessions/compulsions: Intrusive thoughts, distressing repetitive rituals
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If yes, specify
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Body dysmorphia: Negative body image.
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If yes, specify
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Eating disorders: Binging, purging food restriction, etc.
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If yes, specify
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Attention/hyperactivity: Problems focusing, paying attention, sitting still.
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If yes, specify
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Psychosis: Hallucinations, delusions, paranoia, etc.
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If yes, specify
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Medical history
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Medical and physical conditions (non-psychiatric)
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Physical ROS
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Neurological conditions — Head injury, seizure, stroke, migraine, etc.
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If yes, specify
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Endocrine conditions — Diabetes, thyroid problems, or etc.
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If yes, specify
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Respiratory conditions: Sleep apnea, asthma, COPD, breathing issues
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If yes, specify
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Cardiovascular conditions — High blood pressure, cholesterol, or etc.
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If yes, specify
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Chronic pain – musculoskeletal or neurological related pain conditions
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If yes, specify
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Gastrointestinal conditions — Nausea, vomiting, diarrhea, constipation or etc.
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If yes, specify
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Skin conditions — Rash, blisters, or related issues, recent and chronic
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If yes, specify
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Sleep issues
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Trouble falling / staying asleep
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If yes, specify
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Sleepy / drowsy during the day
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If yes, specify
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Social Information
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Occupation
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Education level
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Relationship status
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Living situation
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Children / dependents
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Religious or spiritual beliefs
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Safety concerns
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Dietary / Exercise Information
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Caffeine intake
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Dietary / appetite / eating habits
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Exercise habits / frequency
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Substance Use Information
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Alcohol use / frequency (current or past)
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Cannabis use / frequency (current or past)
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Tobacco use / frequency (current or past)
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Recreational drug use / frequency (list all, current or past)
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Family Health History
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Family mental health conditions
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Family physical health conditions
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