PACIFIC PSYCHIATRY, INC.

Transcription

1 PACIFIC PSYCHIATRY, INC. Douglas P. Murphy, M.D. Child & Adolescent and General Adult Psychiatry 175 Santa Rosa Street, San Luis Obispo, CA Phone: (805) ; FAX: (805) ADULT DEMOGRAPHIC, DEVELOPMENT & TREATMENT HISTORY QUESTIONNAIRE CLIENT NAME: IDENTIFICATION DOB: AGE: SEX: Male Female Address: SS#: Marital Status: Occupation: Employer: Home Phone: Work Phone: Spouse/SO: Sex: Age: DOB: Person to be notified in case of emergency: Address: Phone Number: Referred by: 1. Do you have a primary care doctor (PCP)? Yes No 2. Do you have a therapist? Yes No 3. Have you seen your PCP within the last year? Yes No 4. Have you had a physical exam within the last year? Yes No HEALTH CARE PROVIDERS Primary Care Doctor Therapist Name Phone Name Phone Address FAX Address FAX City/State/Zip City/State/Zip Who else lives at home with you? RELATIONSHIP AGE HEALTH PAC*-Adult-DemoDevTx *

2 ADULT DEMOGRAPHIC, DEVELOPMENT & TREATMENT HISTORY QUESTIONNAIRE Page 2

3 ADULT DEMOGRAPHIC, DEVELOPMENT & TREATMENT HISTORY QUESTIONNAIRE Page 3 CURRENT PROBLEM 1. What are the reasons for the current evaluation (check all that apply): Mood Problem Anxiety Problem Emotional Problem Thinking Problem School Problem Social Problem Marital Problem Other Specify: 2. Please briefly describe the nature of the current problem: 3. How long have these problems been evident: 2 months or less 3 to 6 months 7 to 12 months More than 12 months 4. Have you previously been evaluated for this problem? If so, when and by whom? 5*. Please list all medications you are currently taking (*if necessary, continue on the reverse side): Medication Dose Reason Year Outcome 6. Is there an allergy to medications or other allergy? Yes No If yes, allergic to: Foods Drugs Dusts or pollens Other To which medications are you allergic? PSYCHIATRIC TREATMENT HISTORY 7*. Please list in chronological order (first to last), all behavioral health professionals (psychiatrist, psychologist, other mental health practitioner) with whom you have previously received evaluation or treatment, including the location, year and reason for treatment (*if necessary, continue on the reverse side): Clinician Location Year Reason It is important that you bring a copy of medical and psychological records with you to your first appointment.

4 ADULT DEMOGRAPHIC, DEVELOPMENT & TREATMENT HISTORY QUESTIONNAIRE Page 4 8. Have any of the following diagnoses been related to your care in the past? Aphasic or Language Difficulty Yes No Neurological Disorder Yes No Seizure DO or Convulsions Yes No Post-traumatic Stress Yes No Autistic or Mentally Retarded Yes No Psychotic Disorder Yes No Brain Injury Yes No Seizure Disorder Yes No Depression or Anxiety Yes No Slow Learner or Learning Disabled Yes No Attention Deficit/Hyperactivity (ADHD) Yes No Tic or Tourette s Syndrome Yes No Please provide here any additional information from questions 5 & 7 on previous page current medications and list of behavioral health professionals including the location, year and reason for treatment. FAMILY PSYCHIATRIC HISTORY 1. Have any blood relatives experienced psychiatric problem(s)? Yes No 2. Have any blood relatives been treated for psychiatric problem(s)? Yes No 3. Have any blood relatives been treated in a psychiatric hospital? Yes No 4. Have any blood relatives experienced a substance abuse problem? Yes No 5. Have any blood relatives been treated for a substance abuse problem? Yes No If any yes answer to questions 1-5, please state which relative(s) and the problem/treatment: Psychiatric Problem Relative Treatment Received

5 ADULT DEMOGRAPHIC, DEVELOPMENT & TREATMENT HISTORY QUESTIONNAIRE Page 5 MEDICATIONS CHECK LIST Please thoroughly review the following medications. Circle any medication you currently or have ever taken for whatever reason, even if it was taken just once. Include drugs used recreationally. ANTIDEPRESSANT SSRI Prozac (fluoxetine), Zoloft (sertraline), Paxil (paroxetine), Luvox (fluvoxamine), Celexa (citalopram), Lexapro (excatalipram) SNRI Effexor (venlafaxine), Cymbalta (duloxetine), Pristiq (desvenlafaxine) NDRI Wellbutrin (bupropion) Other Remeron (mirtazipine), Serzone (nefazidone), Viibryd (vilazodone), Desyrel (trazodone) TCAD - Elavil (amitriptyline), Tofranil (imipramine), Pamelor (nortriptyline), Norpramin (desipramine) Anafranil (clomipramine), Sinequan (doxepin), Vivactil (protriptyline) MAOI Nardil (phenelzine), Parnate (tranylcyromine), Marplan (isocarboxazid) ANTI-ANXIETY SLEEP Klonapin (clonazepam), Ativan (lorazepam), Xanax (alparzolam), Valium (diazepam) Buspar (buspirone) Benzodiazepine: Restoril (temazepam), Klonapin (clonazepam), Ativan (lorazepam), Chloral Hydrate* Non-Benzo: Ambien (zolpidem), Sonata (zaleplon), Lunesta (eszopiclone); Benadryl (diphenhydramine) Melatonin-Ag: Rozerem (ramelteon), Melatonin (diphenhydramine); Antidepressant: Desyrel (trazodone); Elavil (amitriptyline); Doxepin (Sinequan); Seroquel (diphenhydramine); STIMULANT/ADHD Methylphenidate: Ritalin, Concerta, Focalin, Vyvanse, Ritalin LA, Methylin, Metadate Dextroamphetamine: Adderall, Dexedrine, Dexedrine Spansules, Dextrostat Nonstimulants: Strattera (atomoxatine), Provigil (modafinil), Catapres (clonidine), Intuniv or Tenex (guanfacine) MOOD STABILIZER Lithium, Lithobid, Eskalith, Depakote (valproic acid), Tegretol (carbamazepine), Trileptal (oxcarbazine) Lamictal (limotragine), Topamax (topiramate), Neurontin (gabapentin) NEUROLEPTIC PAIN NOVEL - Risperdal (risperidone), Zyprexa (olanzepine), Seroquel (quetiapine), Geodon (ziparzidone), Abilify (aripiprazole), Invega (paliperidone), Fanapt (iloperidone), Clozaril (clozapine) TYPICAL Haldol (haloperidol), Prolixin (fluphenazine), Trilafon (perphenazine), Orap (pimozide), Navane (thiothixene), Stelazine (trifluoperazine), Loxitane (loxapine), Moban (molindone), Thorazine (chlorpromazine), Mellaril (thioridazine). Neurontin (gabapentin), Lyrica (pregabalin), Gabitril (tiagabine), Topamax (topiramate), Depakote (valproic acid) Darvocet, Fiornal, Norco, Percoset, Tylox, Vicodin, Codeine, Methadone, Morphine, MSContin, Oxycodone, Dilaudid SUBSTANCE ABUSE Alcohol Dependence - Antabuse (disulfiram), Campral (acamprosate), ReVia (naltrexone) Other Drug Dependence - Methadone, Suboxone (buprenorphine & naltrexone), Subutex (buprenorphine) Withdrawal - Tranxene (clorazepate), Librium (chlordiazepoxide), Catapres (clonidine),

6 ADULT DEMOGRAPHIC, DEVELOPMENT & TREATMENT HISTORY QUESTIONNAIRE Page 6 PSYCHIATRIC REVIEW OF SYMPTOMS/PROBLEMS LIST Please review the following psychiatric symptoms. Please circle or check the box next to (to the left of) any symptom you are currently experiencing or have ever in the past experienced to a degree that would be considered ABNORMAL. MOOD ANXIETY TRAUMA DEPRESSION Depressed Mood; Insomnia; Decreased Interest in Pleasurable Activity; Unreasonable Guilt or Worthlessness; Low Energy; Poor Concentration; Decreased Appetite; Extremely Low Physical Activity; Suicide Thoughts; Suicide Plan; Suicide Attempt MANIA Abnormally Elevated Mood; Abnormally Irritable Mood; Decreased Need for Sleep; Racing Thoughts; Rapid Pressured Speech; Distractibility; Extremely Physically Active; Risky Pleasure-seeking Behavior (out-of-control spending, sexual indiscretions, uncharacteristic fighting). PANIC A Distinct Period of Intense Fear; Heart Pounding; Dizziness Numbness & Tingling; Chest Pain; Shortness of Breath; Sweating; Shaking or Trembling; Nausea; Choking; Overwhelming Fear of Death; Fear of Losing Control or Going Crazy; Derealization/Depersonalization;. GENERALIZED Frequently Overanxious; Excessive Worry; Irritability; Muscle Tension; Feeling Keyed Up; Easily Fatigued; Difficulty Concentrating; Sleep Disturbance. PHOBIA Excessive Fear of a Specific Object or Situation; Fear of Leaving Home; Fear of Social Situations. OCD Repeated Fear or Distressing Thoughts or Images About: Germs or Contamination; Order/Symmetry; Something Terrible Happening; Checking Stove, Light Switches, etc. Harming Self or Others; Repetitive Behaviors or Mental Acts Such As: Checking Stove, Light Switches, etc.; Ordering & Arranging; TRAUMATIC STRESS History of Traumatic Event; Avoidance of Symbols associated with the Trauma; Washing, Cleaning, Grooming; Repetitive Routines; Need to Confess or Seek Reassurance; Re-experiencing the Event in Flashbacks or Nightmares; Hyperactive Startle Response; Emotional Numbing HEAD TRAUMA History Head Injury; Memory Impairment; Cognitive Impairment; Speech Impair; EATING DISORDER PSYCHOTIC Poor Focus and/or Organization; Personality Change; Uncharacteristic Impulsivity; ANOREXIA Restricting Food; Refusal to Maintain Body Weight; Stopped Menstruating. BULIMIA Binge Eating; Purging (vomiting, laxatives, diuretics, enemas, fasting or exercise). Delusions; Hallucinations; Disorganized Speech; Disorganized Thought or Behavior. IMPULSE CONTROL TICS INATTENTION Diminished Focus and Attention; Not Follow Through on Tasks; Poor Organization. HYPERACTIVITY Fidgets; Often On The Go or Driven by a Motor ; Inappropriately Runs & Climbs; IMPULSIVITY Often Interrupts or Intrudes on Others; Difficulty Awaiting Turn; Blurts Out Answers. OPPOSITIONAL Oppositional & Defiant; Argues with Adults; Loses Temper; Annoys People. Vocal Tics; Motor Tics.

7 ADULT DEMOGRAPHIC, DEVELOPMENT & TREATMENT HISTORY QUESTIONNAIRE Page 7 GENERAL MEDICAL HISTORY 1. Are you? Right Handed Left Handed Use Either Hand 2. Have you had a physical exam in the last year? Yes No 3. Please review the following list of medical problems and circle any problem you have had. For each circled problem, please give details on the reverse side of this page. Anemia Asthma Concussion Convulsion Seizure or Epilepsy Eczema (winter dry skin) Encephalitis Frequent Ear Infection Head Injury Hearing Problem Hyperthyroid Measles Meningitis Migraine Headache Pneumonia Poisoning or Overdose Psoriasis Salmonella infection Tremor Urinary Problem Vision Problem For questions 4 7, if necessary, continue on the reverse side of this page. 4. Have you previously had an operation? Yes No If yes, describe the reason for each operation and give the age: 5. Have you ever been hospitalized for medical reasons other than for an operation? Yes No If yes, described the reason for admission and give the age: 6. Have you ever been to the emergency room or treated by a physician because of an accidental injury? Yes No If yes, describe each accident and give the age: 7. Have you ever experienced a head injury, concussion or been unconscious? Yes No If yes, how many times: Describe the circumstances, and give the age:

8 ADULT DEMOGRAPHIC, DEVELOPMENT & TREATMENT HISTORY QUESTIONNAIRE Page 8 Past Medical History: Please list all medical conditions you have experienced which have been the subject of medical evaluation and/or treatment. Include any additional information for affirmative responses to questions 3 7. Please list in chronological order (first to last), and include the Medical Problem, at what Age the problem became the subject of concern or treatment, the type of Treatment rendered (medication, surgery, physical therapy, etc) and the Outcome, whether the problem is now resolved or treatment is ongoing. Medical Problem Age Treatment Outcome

9 ADULT DEMOGRAPHIC, DEVELOPMENT & TREATMENT HISTORY QUESTIONNAIRE Page 9 DEVELOPMENTAL QUESTIONNAIRE PARENTS Married Divorced Separated Never Married Father Step-mother or Significant Other Name Work Name Work City/State/Zip Educ Level City/State/Zip Educ Level Mother Step-father or Significant Other Name Work Name Work City/State/Zip Educ Level City/State/Zip Educ Level As a child, you lived with (check one): Both parents Relatives who are not parents A single parent A foster family Mother and step-father Adoptive parent(s) Father and step-mother In a treatment facility If a treatment facility, specify type: SIBLINGS Chronological Order from Oldest to Youngest (if more siblings check box). Name Sex Age Half-Step Live with School BIRTH & EARLY DEVELOPMENTAL HISTORY 1. How old was your mother when you were born: 2. How old was your father when you were born: Yrs. 4. To the best of your understanding, was this a planned pregnancy? Yes No 3. Were there any known maternal health complications when you were born? Yes No 3. Were there any known pregnancy complications when you were born? Yes No 5. Was there any known birth trauma when you were born? Yes No 6. Was there any known prenatal exposure to drugs or alcohol? Yes No If yes, which: 7. According to your best understanding, did you accomplish the following developmental milestones appropriately and on time? Yrs. Walking Yes No Talking Yes No Sleeping Yes No Eating Yes No Toilet Training Yes No

10 ADULT DEMOGRAPHIC, DEVELOPMENT & TREATMENT HISTORY QUESTIONNAIRE Page Was there any known Child Abuse or Neglect? Yes No If yes, which: Neglect. Physical Abuse. Sexual Abuse 9. Was there trouble with bed wetting? Yes No 10. In the space below, please briefly provide in your own words a description of your life growing up. Please include issues you think may have effected your emotional development.

11 ADULT DEMOGRAPHIC, DEVELOPMENT & TREATMENT HISTORY QUESTIONNAIRE Page 11 SOCIAL, EDUCATIONAL & EMPLOYMENT HISTORY 1. You currently live: Married. Alone. With Roommate(s). Significant Other. 2. Please list the names of all persons with whom you now reside. Name of Resident Age Relationship Occupation How long? 3. Current employment: Name of Employer Location Job Title How long? 4. Past Employment: Name of Employer Location Job Title When 5. Highest Grade Completed (circle one): K Please check the box indicating your highest level of academic completion: Graduated High School Some College Coursework Graduated Associates Degree Some Trade School Work Completed Vocational Certific Completed Computer Certific Some University Coursework Graduated Bachelors Degree Some Post-Graduate Work Graduated Masters Degree Some Post-Graduate Work Graduated Doctoral Degree HIGH SCHOOL: City Grades Attended Performance COLLEGE OR UNIVERSITY: City Grades Attended Degree Earned

12 ADULT DEMOGRAPHIC, DEVELOPMENT & TREATMENT HISTORY QUESTIONNAIRE Page In general, how has your academic performance (grades) been? Below Average Average Above Average 7. Were you ever suspended for disciplinary reasons: Yes No 8. Were you ever evaluated for Special Education: Yes No If yes, when was the initial Individualized Educational Plan (IEP) performed? Yes No 9. Were you ever accepted for Special Educational Services? Yes No Please bring a copy of any academic assessment records you may have to your initial appointment. LEGAL HISTORY 1. Have you ever experienced legal trouble, arrest or prosecution for any reason: Yes No If yes, please provide a brief description of the issue: 2. Have you ever been convicted of a DUI or Wet Reckless for any reason:? Yes No If you have legal issues and/or are on diversion, probation, or other legal action such as probation with a professional governing body, it is important that you bring a copy of related documentation AND contact information for your probation officer, attorney with you to your initial appointment.

13 ADULT DEMOGRAPHIC, DEVELOPMENT & TREATMENT HISTORY QUESTIONNAIRE Page 13 DRUG & ALCOHOL HISTORY Have you ever suspected that you might have a substance abuse problem? Yes No DRUG & ALCOHOL USE INVENTORY - Please thoroughly review the following drugs. Circle each drug you currently or have ever taken for whatever reason, even if it was taken just once. Include drugs used recreationally. Ever Used? Ever a Problem? Age/Year 1 st time/regular Use Use Past 6 mo Frequency/Amount Last Use Alcohol Yes No Yes No Marijuana Yes No Yes No Hashish Yes No Yes No Cocaine Yes No Yes No Crack Yes No Yes No Methamphetamine (crank) Yes No Yes No Amphetamine Yes No Yes No Ecstasy (MDMA) Yes No Yes No Heroin Yes No Yes No Speedball Yes No Yes No Methadone Yes No Yes No Vicodin Yes No Yes No Percodan Yes No Yes No Codeine Yes No Yes No Demerol Yes No Yes No Oxycontin Yes No Yes No Dilaudid Yes No Yes No Valium Yes No Yes No Xanax Yes No Yes No Rohypnol Yes No Yes No Seconol (reds) Yes No Yes No Quaalude Yes No Yes No Other Barbiturates (downers) Yes No Yes No Sleeping Pills Yes No Yes No Soma Yes No Yes No LSD Yes No Yes No Mushrooms Yes No Yes No Mescaline (Peyote) Yes No Yes No PCP (Angel Dust) Yes No Yes No Ketamine (Vitamin K) Yes No Yes No Nitrous Oxide Yes No Yes No Glue Yes No Yes No Gasoline Yes No Yes No Nicotine Yes No Yes No Other Yes No Yes No

14 ADULT DEMOGRAPHIC, DEVELOPMENT & TREATMENT HISTORY QUESTIONNAIRE Page 14 PLEASE COMPLETE THE FOLLOWING: CAGE Questions. No. Questions Yes/No 1 Have you ever felt you needed to Cut down on your drinking? Yes No 2 Have you ever felt Guilty about drinking? Yes No 3 Have people Annoyed you by criticizing your drinking? Yes No 4 Have you ever felt you needed a drink first thing in the morning (Eyeopener) to steady your nerves or to get rid of a hangover? [1][2] Yes No Kitchens JM (1994). "Does this patient have an alcohol problem?". JAMA 272 (22): PAC*-Adult- DemoDevTx *