Jennifer Teitelbaum Palmer M.D Keswick Road Suite 100 Baltimore MD 21211
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1 PERSONAL INFORMATION - Please fill out this form as completely as you can. Please print your answers. Today s Date First Last Birthdate Social Security Number Ethnic Identity Gender Identity Marital Status Occupation Religion (if an important part of your identity) Contact Information - Please give your home address. Please circle the appropriate letter letting me know if I can leave a full message (M), call-back number only (C), or no message (N). Address Home M C N City Cell M C N State Work M C N Zip Code M C N Emergency Contact - Please tell me the name of someone to contact in an emergency. Best Relationship Insurance Information - Although I do not participate with any insurance plans, it is sometimes helpful for me to have your insurance information in case you need hospitalization. Plan Subscriber Policy Number Group Number Pharmacy - Please provide contact information for the primary pharmacy you use for your prescriptions. Pharmacy Pharmacy Plan Number(s) (from insurance card) Rx BIN (on insurance card) Referral Source - Please tell me who suggested that you see me. Relationship 1
2 DOCTORS AND THERAPISTS- Please list all doctors and therapists you see regularly. Please also list any past psychiatrists and therapists and when you last saw them. Continue on back if needed. MEDICAL HISTORY Medical Problems - Please list all major medical problems, injuries and treatments. Continues on next page. Continue on back if needed. Medical Problem When Diagnosed Treatment(s) Treatment Dates 2
3 Surgeries - Please list all surgeries you have had, when and for what conditions. Continue on back if needed. Operation When Performed Reason for Procedure Current Medications and Supplements - Please list all medications and supplements (prescribed and over-the-counter) you take regularly. Continue on back if needed. Medication Dose Frequency Reason Prescribed Allergies and Adverse Reactions - Please list any medications or foods to which you have had a bad reaction, including problems with anesthesia. Continue on back if needed. Medication or Food Reaction 3
4 Substance History - For any substances you have used, please indicate date of last use, the maximum amount and frequency used, and whether you ever used it intravenously if applicable. Continue on back if needed. Substance Last Used Max Amount Max Frequency Ever Used I.V.? Alcohol Cocaine Marijuana Hallucinogens Inhalants Heroin or opioid pain medication Amphetamines, bath salts, prescribed stimulants Sedatives Tobacco products Recent Symptoms and Tests - Please check any symptoms and/or tests you have had in the past year. Please indicate which body part was tested where applicable (Xray of: chest, e.g.). Continue on back if needed. Fatigue Swollen legs or feet Anemia Seizures Fever Calf pain Easy bruising bleeding X-ray of: Unintentional weight loss gain Night sweats or hot flashes Difficulty swallowing Rash CT scan of: Heartburn Changes in moles MRI of: Enlarged lymph nodes Chest pain New breast lump discharge skin change Ultrasound of: Intolerance to cold heat Shortness of breath New testicular lump swelling EKG Increased thirst appetite urination Nausea Vomiting Diarrhea Constipation Pain in joints muscles Stress test Loss of appetite Bloody black or claycolored stool Limb or face numbness or weakness EEG Hair loss or changes Yellow skin eyes Headaches Others not listed: Hearing or vision problems Nosebleeds Mouth sores or dental problems Trouble urinating Bloody pink coca-cola colored urine Abnormal vaginal bleeding missed periods genital discharge Memory problems Coordination problems Dizziness or fainting 4
5 PAST PSYCHIATRIC HISTORY Psychiatric Hospitalizations - Please list any psychiatric hospitalizations you have had. Continue on back if needed. Hospital Dates in Hospital Reason Admitted Past Psychiatric Medications - Please list names of any psychiatric medications (such as antidepressants, antipsychotics, mood stabilizers, stimulants, sedatives) that you remember taking in the past. Continue on back if needed. Medication When Prescribed Frequency (if known) Max Dose (if known) How Long Taken at Max Dose (if known) 5
6 FAMILY PSYCHIATRIC HISTORY Family Psychiatric Illness History - Please list any blood relatives diagnosed with a mental illness. Continue on back if needed. Relation to You Gender Diagnosis (check all that apply) Treatment (check all that apply) Family Suicide History - Please list any blood relatives who have died by suicide. Continue on back if needed. Relation to You Gender Age at Suicide 6
7 Current Psychiatric Symptoms - Please check any symptoms you are experiencing now. Continue on back if needed. Sad or don t care Difficulty at school or work Not needing much sleep Can t throw things away Irritability Can t make decisions Uncharacteristic impulsive or dangerous behavior Trouble concentrating Don t enjoy things Racing thoughts, feeling talkative or talking loud Generalized anxiety feelings Panic attacks Appetite increase or decrease Not good at things Lots of new plans or insights Binge eating Trouble falling asleep or staying asleep Guilt over bad deeds or deserve punishment Suspicious of others trying to harm you Afraid to get fat Poor energy Worrying about health or even rotting from the inside from disease Thoughts being inserted removed blocked broadcast by outside force Starving self to control weight Poor motivation Feeling worthless or hopeless Getting messages from the radio or TV Vomiting, laxative or diuretic use to control weight Trouble getting started Life is not worth living Arms and legs being moved against your will by an outside force Overexercising to control weight Not getting out Thoughts of suicide Hearing or seeing things Others not listed: Interpersonal difficulty, even physical altercations Cutting or hurting self Needing to count or check things Interacting less Too much energy Afraid of or avoid things 7
8 WOMEN S HISTORY QUESTIONS Family Postpartum History - Please list any female blood relatives who suffered from an episode of mental illness that began soon (roughly within the first year) after giving birth. Continue on back if needed. Female Relative Post-Partum Diagnosis (please check all that apply) or Disorder or Disorder or Disorder or Disorder or Disorder or Psychosis or Psychosis or Psychosis or Psychosis or Psychosis Reproductive Events - Please indicate the number of events and in what year(s) they occurred. Event Number When Occurred Live births Miscarriages Elective abortions Stillbirths or 3rd trimester losses Menstrual History Age at your first menstrual period? Are your cycles regular? Date of your last menstrual period? Premenstrual Symptoms - Have you experienced symptoms that start before your period and stop with bleeding onset? Please check severity level of each. Symptom None Mild Moderate Severe Depressed mood/hopelessness/self-deprecating thoughts Anxiety/tension/feeling keyed up or on edge Easily sad/tearful/increased sensitivity to rejection Anger/irritability Decreased interest in usual activities Difficulty concentrating 8
9 Symptom None Mild Moderate Severe Fatigue/lack of energy Overeating/specific food cravings Insomnia OR sleeping more than usual (circle one) Feeling overwhelmed/out of control Breast tenderness, headache, joint/muscle pain, bloating How badly have these symptoms interfered with your: None Mild Moderate Severe Work and/or home responsibilities? Social activities? Relationships with family, friends and coworkers? If yes to any of the above symptoms, do they occur with every or most cycle(s)? Reproductive Treatments and Mood Symptoms - Please indicate whether hormone treatments have affected your mood in any way, and whether you have ever experienced a postpartum mood episode. Continue on back if needed. Have you ever used a hormone birth control method (pills, Nuva Ring, Patch, IUD) or other hormone treatment (such as for polycystic ovarian syndrome or missed menses) or hormone replacement therapy? If yes, which treatments? Did you experience any mood changes (better or worse) with these treatments? If yes, please describe: Have you experienced any mood symptoms that started within 4 weeks of delivery or pregnancy termination? If yes, please describe: 9
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CAPS PAINCARE Page 1 of 5 Today s : / / SSN (last 4 digits): xxx-xx - Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left Type of Accident/Injury: Auto Work Personal Injury