Psychiatric Evaluation Intake Form
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1 Patient Contact Information Psychiatric Evaluation Intake Form Patient Name: Date of Birth: Age: Last First MI Address: Contact phone number: address: Emergency Contact/Number/Relationship: Primary Care Physician: Tel: Referred here by: Reason For Your Visit: 1
2 Depression/Mania/Psychosis/Eating/PTSD/Panic/GAD/OCD/PD/Drugs Previous Treatment Please list any inpatient mental health hospitalization Hospital name/dates/reason Have you ever attempted to harm/kill yourself? If so, please list the occurrences below: Previous Outpatient Psychiatric History: Have you ever been treated for any of the following by either a family doctor or psychiatrist (check all that apply), if so, please list medications given: Depression ADHD Bipolar (Manic / Depressive) Disorder Anxiety OCD Schizophrenia Panic Attacks PTSD Alcohol Problems (including AA) Anorexia/ Bulimia Binge-eating Drug Problems ECT treatment MD Notes Current and Previous MEDICAL Problems (Check all that apply) High Blood Pressure Diabetes Heart Attacks Strokes Hepatitis Asthma Thyroid Sleep Apnea COPD Seizures Sexual Disease Heart Failure Hepatitis HIV Fibromyalgia Hysterectomy Tubal Ligation Migraines Urinary Cancer Bleeding Problems GI Problems Head Injury Kidney Cholesterol MD Notes 2
3 List all prior surgeries and hospitalizations for MEDICAL illnesses Last menstrual period (if applicable) Contraceptive method: Please List all current medications below (include birth control pills, over the counter medication and herbal remedies (i.e. decongestants, St. John s Wort, etc) Pharmacy: Phone #: Allergies (Medication/Food): Family History: Has anyone in your family ever been treated for any of the following (please check all that apply and when appropriate indicate paternal or maternal) Father Mother Aunt Uncle Brother Sister Children Grandparent Depression Anxiety Panic Attacks Post-Traumatic Stress Bipolar/Manic Depression Schizophrenia 3
4 Alcohol Problems Drug Problems ADHD Suicide Attempts Psychiatric Hospital Stay Father Mother Aunt Uncle Brother Sister Children Grandparent What MEDICAL Problems run on one or both sides of the family? (Diabetes, High Blood Pressure, etc) Substance Use Do You Use Tobacco Products? (Packs/amount per day) When was your last drink with alcohol? In the past 30 days, about how many of those days have you had at least one alcoholic drink? What is the maximum number of drinks you have had in one day in the past month? drinks DUI DWI Public Intoxication Seizures DT s Blackouts AA/NA Meetings Detox/Rehab? Please check if you have EVER used any of the below substances: Marijuana Cocaine IV Drugs Xanax (Ativan, Valium, Benzodiazepines Amphetamine Heroin PCP Hallucinogens (LSD, Mushrooms) Ecstacy Pain Pills GHB Anabolic Steroids Inhalants Diet Pills Diuretics Sleeping Pills Tranquilizers Laxatives Caffeine 4
5 Social History: 1. Where were you born and raised? 2. Problems with developmental milestones? 3. Single Married Divorced Widowed Separated 4. Total number of marriages? How many children do you have? 5. Housing: House Apartment With Friends With Family Homeless 6. Who lives with you? 7. Highest degree obtained and other training: High school graduate G.E.D. 4 year college degree Graduate School Junior college degree or technical school diploma Military Honorable Discharge? 8. What best describes your current employment status? (Check all that apply) a. Employment Status b. Student Status c. Volunteer Status Unemployed, looking for employment Unemployed, not looking for employment Full-time Part-time Volunteer Part-time Volunteer Full-time Full-time employed Part-time employed Not a student No Volunteer Work Retired Self-employed On welfare Disability 9. What is your occupation? 10. What do you do for exercise (and frequency)? 11. Type of diet? 12. Support system: 5
6 13. Hobbies: 14. History of physical/sexual abuse: 15. Have you ever been in jail or prison (and reason)? Review of Systems: (please circle all that apply) General : Recent weight loss, recent weight gain, weakness, fatigue, night sweats, fevers Eyes : Double vision, blurred vision Ears, nose, throat: Dry mouth, hoarseness or other voice change, difficulty swallowing Respiratory: Cough, sputum (color: ; quantity ), shortness of breath at rest, shortness of breath with activity Cardiovascular: Heart trouble, chest pain or discomfort, palpitations, shortness of breath while lying flat, swelling in legs or ankles Gastrointestinal: Ulcer, trouble swallowing, heartburn, change in appetite, nausea, diarrhea, constipation, rectal bleeding or dark or tarry stools Urinary: Increased frequency of urination, incontinence, reduced caliber or force of urinary stream,hesitancy, dribbling Musculoskeletal: Muscle or joint pain or stiffness, joint pain, redness, swelling Psychiatric: Anxiety, depression, changes in mood, thoughts of suicide Neurologic: Headaches, dizziness, vertigo, fainting, blackouts, seizures, weakness, paralysis, numbness or loss of sensation, tingling or pins and needles, tremors or other involuntary movements, seizures 6
7 7
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Psychiatric Evaluation Intake Form
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