Pharmacy Information: Name: Address: Phone: Emergency Information (In case of emergency, contact): Name: Relationship: Phone:

Transcription

1 Willow Creek Clinic Kim M. Schmidt, PMHNP-BC 130 S. Bartstow St., Suite 1B Eau Claire, WI Phone: (715) Fax: (715) Intake and Personal History Form Name: Social Security Number: Gender: F M Date of Birth: Age: Form completed by (if someone other than client): Address: City: State: Zip Code: May we contact you at your listed address: Y N Phone: (Home) (Cell) _ May we contact you at your home and/or cell phone number: Y N Address: May we contact you via Y N Person Responsible for Payment: Social Security Number: Relationship to Patient: Signature of Person Responsible for Payment: Date: (This must be signed for services to begin) Pharmacy Information: Name: Address: Phone: Emergency Information (In case of emergency, contact): Name: _ Relationship: Phone: Referral Source: How did you hear about our office or from whom did you hear about our office? Telephone Number: _ Fax Number: Do you want us to contact them? Y N Primary reason(s) for seeking services (Please describe in detail): Development Are there special, unusual, abusive or other traumatic circumstances that affected your development? Y N If yes, please describe: Please describe significant events in your life including marriages, separations, divorces, births, and, deaths: Social Relationships Marital Status (Married, divorced, separated, single, widow): Assessment of current relationship (if applicable): Good Fair Poor Children (Please list names and ages): Siblings (Name, ages, relationship to patient): Family Structure: (Who lives in your current household? Please give relationship to each person.): Previous Marriages (Please list dates and reason for separation): Sexual Orientation: Comments: Please describe your social support network (check all that apply): Family Neighbors Friends Students Co-Workers Community Group Support/Self-Help Group Religious/Spiritual Center (which one):

2 Cultural/Ethnic To which cultural or ethnic group, if any, do you belong? If you are experiencing any difficulties due to cultural or ethnic issues, please describe: Religion (if any): How important are spiritual matters to you? Not at all Little Somewhat Very Much Would you like spiritual/religious beliefs to be incorporated into your counseling? Y N Legal Are you involved in any active cases (traffic, civil, criminal)? Y N If yes, please describe and indicate the court and hearing/trial dates and charges: Are you presently on probation/parole? Y N If yes, please describe: Past History: Traffic Violations: Y N Criminal Involvement: Y N DWI, DUI, etc: Y N Civil Involvement: Y N Education Fill in all that apply: Years of Education: Currently enrolled in school? Y N High School Grad/GED College: # of Years: Graduated: Y N Major: Other Training: Special Circumstances (e.g., learning disabilities, gifted): Employment Occupation: Employer: Stress Level of Current Position: Low Medium High Currently: FT PT Temp Laid-Off Disabled Retired Social Security Student Other (Describe): Summarize jobs you ve had including favorite and least favorite as well as how long you worked there: Any work-related problems: Have you been/are you current in the military? Y N (If no, skip the remainder of this section.) Branch: _ Date of : Type of : Rank: Were you in combat: Y N Please describe if yes: Leisure/Recreational Describe special areas of interest or hobbies (e.g., art, books, crafts, physical fitness, sports, outdoor activities, church activities, walking, exercising, diet/health, hunting, fishing, bowling, traveling, etc.): Activity How Often Now? How Often in the Past?

3 Medical/Physical Health Primary Care Physician: Phone: Address: _ Fax: Past General State of Health: Excellent Good Fair Poor Current Weight: Usual Weight: Maximum Weight: Minimum Weight: Height: Sexual History: (Answer only as much as you feel comfortable) Age at time of first sexual experience: Number of sexual partners: Any history of sexually transmitted disease: History of abortion: History of sexual abuse, molestation or rape: Current sexual problems: Check all that apply below: Hay Fever Skin Trouble Mumps Cataracts Measles Tonsillitis Rheumatic Fever Sinusitis Allergies Goiter Anemia Asthma Cancer Bronchitis Tumor Pleurisy Blood Diseases Pneumonia Leukemia HIV Fibromyalgia Tuberculosis Breast Trouble Heart Disease Varicose Veins Phlebitis Polyps Hypertension Kidney Infections Stroke Kidney Stones Ulcers Bladder Trouble Jaundice Diabetes Gallstones Syphilis Liver Disease Gonorrhea Pelvic Infection Hernias Hepatitis Sexual Problems Parasites Hemorrhoids Dysentery Arthritis Colitis Gout Migraines Epilepsy Paralysis Polio Mental Illness Alcoholism Depression Nervous Breakdown Abnormal Bone Growth Other Please describe any major illnesses, injuries, head trauma, or operations you have had including dates: Any history of seizures or seizure-like activity: Sleep Behavior: Sleepwalking, nightmares, recurrent dreams, current problems (getting up, going to bed): Radiology: Prior abnormal lab tests, X-rays, EEG, etc:

4 Recent Symptoms (Please check the symptoms that you have experienced recently): General Weakness Fatigue Fever Chills Night Sweats Fainting Tire Easily Disturbed Sleep Weight Changes Neck Enlargements Stiff Neck Soreness Lymph Masses Guarded Radiating Head Headaches Injuries Bumps Contusions Migraines Coma Concussion TBI Lungs Cough Phlegm Blood Short of Breath Wheezing Congestion Inhalant Eyes Blurred Vision Glaucoma Redness Burning Swelling Dryness Tearing Loss of visual field Heart Murmur Palpitation Rapid Heartbeat Swollen Extremities Cold Extremities Blue Extremities Chest /Pressure Varicose Veins Blood Clots Ears Hard of Hearing Deafness Ringing Earache Loss of Balance Dizziness Room Spins Gynecological Spotting Between Periods Contraception Type Menstrual Cramps Age at First Period Spotting After Menopause Age at Menopause Duration of Cycle Duration of Flow ful Intercourse # of Pregnancies Irregular Periods # of Births Hot Flashes # of Miscarriages # of Abortions Gastrointestinal Genitourinary Abdominal Bloating Urgency Nausea Vomiting Straining Sores Belching Heartburn Incontinence Impotence Indigestion Constipation Back Cloudy Urine Irregular Bowel Habits Hemorrhoids Frequency Urine Color: Food Intolerance Gas Burning Bloody Stools Hernias Stones Black Stools Melina Bed Wetting Poor Appetite Diarrhea Small Stream Dribbling Nose Decreased Smell Bleeding Obstruction Post Nasal Drip Deviated Septum Runny Nose Sinus Congestion Dryness Skin Color Changes Nail Changes Hair Changes Moles Rashes Sores Dryness Menstrual Flow Heavy Moderate Light Date of Last Period: Date of Last Pap: Normal Abnormal Musculoskeletal Muscle Muscle Cramps Muscle Weakness Muscle Twitching Joint Deformities Strain/Sprain Misalignment Curvature of Spine Back Injuries Joint Hot Joints Tenderness Joint Stiffness Joint Swelling Mouth Bleeding Gums Sores Dental Problems Bad Breath Loss of Taste Dry Mouth Ulcers Blisters Broken Teeth Blood Anemia Easy Bruising Easy Bleeding Swollen Nodes ful Nodes Sugar in Blood Red Spots Throat Soreness Bad Tonsils Hoarseness Trouble Swallowing Recurrent Infections Endocrine Weight Loss Weight Gain Hoarseness Heat Intolerance Cold Intolerance Breast Changes Hair Changes Extreme Thirst Breasts Lumps Bleeding Nipple Changes Skin Changes Tenderness Cysts Date of Last Mammogram: Psychological Hyperventilation Timid Hallucinations Anxious Loss of Memory Indecisive Troubled Sleep Alcoholism Suicidal Thoughts Insecurity Extreme Worry Irritable Drug Addiction Depression Drug Dependency Sexual Problems Chronic Sleep Disturbances Increased Infections Feeling Tired All the Time Hearing Impairment Lack of Fine Motor Coordination Muscle Spasticity Difficulty Controlling Blood Pressure Body Temperature Changes Weight Gain Changes in Hair Texture Speech Impairment Other Sensory Impairment PHYSICAL CHANGES Dizziness or Imbalance Seizure Disorders Gait Impairments Changes in Skin Texture Thyroid Disease Paralysis Abnormal Bone Growth Double Vision Field Cuts Near-Sightedness Sector Losses Rapid Eye Movement Short and Long-Term Memory Loss Impaired Reading and Writing Skills Trouble Making Decisions Impaired Concentration Listlessness Fatigue Denial Agitation Easily Irritated for Little or No Reason Frequent Mood Changes or Swings Excessive Laughing or Crying Difficulty Relating to Others COGNITIVE CHANGES Impairments of Perception Slowed Thinking Limited Attention Span PSYCHO-SOCIAL CHANGES Lowered Self-Esteem Inability to Cope Inability to Self-Monitor Self-Centeredness Communication Difficulties Impaired Planning or Sequencing Abilities Impaired or Changed Judgment Skills Sexual Dysfunction Difficulty with Emotional Control Lack of Motivation Restlessness

5 Chemical Use History Method of use and amount Alcohol Barbiturates Valium/Xanax Cocaine/Crack Heroin/Opiates Marijuana PCP/LSD/Mescaline Inhalants Caffeine Nicotine Over the Counter Prescription Meds Other Drugs Frequency of use Age of first use Age of Used in last last use 48 hours Yes No Used in last 30 days Yes No Substance Abuse Questions: Describe when and where you typically use substances: Describe any changes in your use patterns: Describe how your use has affected your family or friends (include their perceptions of your use): How do you believe your substance use affects your life? Who or what has helped you in stopping or limiting your use? Have you ever needed detoxification/rehabilitation for alcohol or drugs? Y N If yes, describe with dates and locations: Over the Counter Medications Medication: Type: Dosage: Frequency: Laxatives: Antacids: Diet Pills: _ Pills: Aspirin: Diuretics: Sleeping Pills: Vitamins: Minerals: Herbs: Others: Prescriptions Local Pharmacy Name: Telephone: Fax: Mail Order Pharmacy: _ Telephone: Fax: Medication: Dosage: Frequency: Medication Allergies: I do not have any medication allergies. Medication: Reaction:

6 Family Psychiatric/Substance Abuse History Please list and describe any family members who have/had any psychiatric issues or problems with substance abuse: (i.e. bipolar disorder, depression, anxiety, ADD, substance abuse, autism, learning disability): Prior Psychiatric Treatment History Current Therapist/Clinician: Phone: Address: Fax: Prior Psychiatric Hospitalizations: Y N If yes, please describe (hospital, dates, reason): Have you ever had thoughts, made statements, or attempted to hurt yourself? Y N If yes, please describe: Have you ever had thoughts, made statements, or attempted to hurt someone else? Y N If yes, please describe: Current Psychiatric Medications and Dosage: Prior Trials of Psychiatric Medications: Please check behaviors and symptoms that occur to you more often than you would like them to take place. Aggression Elevated Mood Phobias/Fears Alcohol Dependence Fatigue Recurring Thoughts Anger Gambling Sexual Addiction Antisocial Behavior Hallucinations Sexual Difficulties Anxiety Heart Palpitations Sick Often Avoiding People High Blood Pressure Sleeping Problems Chest Hopelessness Speech Problems Cyber Addiction Impulsivity Suicidal Thoughts Depression Irritability Thoughts Disorganized Distractibility Loneliness Trembling Disorientation Judgment Errors Withdrawing Dizziness Memory Impairment Worrying Drug Dependence Mood Shifts Other(specify): Eating Disorder Panic Attacks _ Please check if there have been any recent changes in the following: Sleep Patterns Eating Patterns Behavior Energy Levels Physical Activity Level General Disposition Weight Nervousness/Tension Describe changes in areas in which you checked above or any other changes noticed: Final Questions Any additional information that would assist us in understanding your concerns or problems: What are your hopes/goals for treatment: Signature: Date: