San Diego Center for the Treatment of Mood Disorders 1
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1 San Diego Center for the Treatment of Mood Disorders 1 DATE NAME Last Middle First REFERRAL HISTORY: How did you find us (via a referral, web search, recommendation)? Please provide the name and phone number of you family physician: Please provide the name and phone number of any specialists that you consult: IDENTIFYING AND BILLING INFORMATION: Social Security number: Driver s license number: Age: Date of Birth: Home phone number: Cell phone number: Work phone number: In what country, city, were you born: OCCUPATION Job description: If not employed currently when was the last time that you worked? EDUCATION HISTORY Highest grade you completed? Name of high school? Name of college (if applicable)? Additional Degrees (if applicable)?
2 San Diego Center for the Treatment of Mood Disorders 2 MARITAL HISTORY If you are currently married: What year were you married? What is the name of your spouse? Have you been married more than once? If so, how many times? If you are currently divorced what year did you and your partner separate? FAMILY HISTORY: If you have children, please list their names and ages: Psychiatric Illnesses: To the best of your knowledge, has anyone in your immediate family struggled with a problem similar to yours? What family member? If more than one family member has struggled with a psychiatric illness similar to yours, please list their names and whether they were treated for said problem: PSYCHIATRIC HISTORY Previous Episodes: Have you had a similar episode in the past? If so, please list the dates of previous episodes: Treatment: Were you treated for a similar episode? Who treated the episode?
3 San Diego Center for the Treatment of Mood Disorders 3 Medication: If you were treated with medication, please list the name and dosage of the medication(s): Diagnosis: Have you ever been officially diagnosed with a psychiatric diagnosis? If so, what was it? PROBLEM HISTORY: Severity Rating: Please use the numbers below to rate the severity of the problem(s) for which you are seeking help. A score of 0 indicates no problem, and a score of 10 indicates the worst level of problem. No Problem Worst Problem Please use select from this list the problem(s) for which you are seeking help and use the severity numbers to grade each of the problems for which you are seeking help (Or if you would rather, use you own words to describe your problem Check all that Apply Problem Type Anxious Worried Fearful Trouble Concentrating Sleep Problems Depressed Sad Avoidance of Friends/Family Feelings of Worthlessness Loss of Ability to Experience Pleasurable Activities Loss of Motivation Loss of Energy Mood Swings Irritability Anger Stress at Work Stressful Medical Problems Financial Stress Recent Death or Loss of a Family Member Severity Level (0=None: 10=Worst)
4 San Diego Center for the Treatment of Mood Disorders 4 DRUG AND ALCOHOL HISTORY Drugs & Alcohol: Are there, or were there, any drug or alcohol problems in your family? If so, which family members have struggled with drugs or alcohol? Have you ever abused alcohol? If so, how old were you when you last abused alcohol? Have you ever used drugs? If so, how old were you when you last used? Have you ever been treated for a drug or alcohol problem, and if so, please describe the treatment: FUNCTIONAL HISTORY What aspect of your problem do you feel interferes the most with your day to day life? _ Has your problem made it difficult or impossible to do the things that you do every day? _ What things in particular have become difficult? Have you ever had to miss work for the problem that you came here for help? How many times? ABUSE AND OR MOLESTATION HISTORY Have you ever been abused? If you were abused as a child, describe it: Emotional abuse? Physical abuse? _ Sexual abuse? If you were abused as an adult, please describe it: Emotional abuse?
5 San Diego Center for the Treatment of Mood Disorders 5 Physical abuse? _ Sexual abuse? If yes to any of the above, please answer the following questions: Who abused you? How often? GENERAL MEDICAL HISTORY If you have any additional medical problems, please list them below: If you are currently taking any medications, please list the names of the medications and dosages in the spaces provided: If you have you ever been hospitalized, please include a list of list below, beginning with the most recent dates: Hospitalization Date Location Reason for Hospitalization
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