Patient History Form
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1 Patient History Form Date: / / NAME: Last First Middle Birthdate: / / Age: Sex: F M Please read the following questions and answer to the best of your ability by placing a check mark in the appropriate boxes or fill in the blank as directed. YOUR COOPERATION IS APPRECIATED. How did you hear about this clinic? OR Referred by: PLEASE STATE IN YOUR OWN WORDS WHY YOU HAVE COME TO ALABAMA PSYCHIATRY AND COUNSELING: PSYCHIATRIC HOSPITALIZATIONS (include where, when, & for what reason): Yes No Have you ever had ECT? Yes No Have you had counseling? Yes No 1
2 SYSTEMS REVIEW (PSYCHIATRIC) PLEASE CHECK: In the past month, have you had any of the following problems? Felt sad or low? Sensitivity or Frequent crying? Felt upset or annoyed at little things? Had trouble enjoying things that used to be fun? Worried that you might hurt yourself or felt like you wanted to die? Had felt bad about yourself or that you are a failure or have let yourself or your family down? Felt Hopeless or Worthless? Had trouble falling or staying asleep? Had felt more self confident? Had felt more energetic and more active then usual? Had racing thoughts (thoughts jump from topic to topic)? Had taken more risks in your daily life? Work? or Other Activities? Felt driven to perform certain acts over and over, such as excessive checking, counting or arranging objects? Felt more nervous and anxious than usual? Worrying too much about different things? Exposed to a significant traumatic event? Had recurrent distressing dreams / nightmares? Felt jumpy or easily startled by noises? Felt emotionally distant from others? Bothered by thoughts or images that repeatedly enter your mind such as concerns with contamination or keeping objects in perfect order? Hear voices or sounds that others do not hear? See things that others do not see? Sleeping too much? Unable to stop worrying? Smell things others don t smell? Had no appetite or been eating too much? Felt more tired than usual or have less energy? Trouble thinking, concentrating or making decisions? Moving or speaking so slowly that other people have noticed? Felt fidgety or restless that you have been moving around a lot more than usual? Felt like you have no one to talk to? Sexual problems? Gender concerns? Difficulties with sexual arousal? Had trouble relaxing? Felt like you are falling apart and going to pieces? Anxiety in social situation? Social phobia? I don t like my body? Intense fear of gaining weight? Excessive fasting to loose weight? Binge eating? Self-induced vomiting? Laxative abuse? Paranoid or suspicious? Felt paranoid or suspicious such as being plotted against, followed or monitored? Memory problems / Forgetfullness? Use of drugs? Abuse of Alcohol? Smoke cigarettes? 2
3 SYSTEMS REVIEW (MEDICAL) In the past month, have you had any of the following problems? GENERAL NERVOUS SYSTEM HEART AND LUNGS Recent weight gain; how much Headaches Chest Pain Recent weight loss: how much Dizziness Palpitations Fatigue Fainting or loss of consciousness Shortness of breath Weakness Numbness or tingling Fainting Fever Memory loss Swollen legs and feet Night sweats Seizure MUSCLE/JOINTS/BONES STOMACH AND INTESTINES KIDNEY / BLADDER Numbness Nausea Frequent urination Joint pain Heartburn Burning on urination Muscle weakness Stomach pain Blood in urine Joint swelling Vomiting Where? Yellow jaundice WOMEN ONLY Increasing constipation Abnormal papsmear EARS Persistent diarrhea Irregular periods Ringing in ears Blood in stools Bleeding between periods Loss of hearing Black stools PMS EYES SKIN OTHER PROBLEMS Pain Redness Redness Rash Loss of vision Nodules/bumps Double or blurred vision Hair loss Dryness Color changes of hands or feet THROAT BLOOD Frequent sore throats Anemia Hoarseness Clots Difficulty in swallowing Excessive Bleeding Pain in jaw 3
4 PAST MEDICAL HISTORY Do you now or have you ever had: Diabetes Heart murmur Crohn s disease High blood pressure Pneumonia Colitis High cholesterol Pulmonary embolism Anemia Hypothyroidism Asthma Jaundice Goiter Emphysema Hepatitis Cancer (type) Stroke Stomach or peptic ulcer Leukemia Epilepsy (seizures) Rheumatic fever Psoriasis Cataracts Tuberculosis Angina Kidney disease HIV/AIDS Heart problems Kidney stones Other medical conditions (please list): Do you now or have you ever had: PERSONAL HISTORY Where were your born & raised? What is your highest education? High school Some college College graduate Advanced degree Marital status: Never married Married Divorced Separated Widowed Partnered/significant other What is your current or past occupation? Are you currently working? : Yes No Hours/week If not, are you retired disabled sick leave? Do you receive disability or SSI? Yes No If yes, for what disability & how long? Have you ever had legal problems? (specify) 4
5 CURRENT MEDICATIONS Please list any medications that you are now taking. Include non-prescription medications & vitamins or supplements: Name of drug Dose (strength & number of pills per day) How long have you been taking this? Drug allergies: No Yes To what? DRUG ALLEGIES 5
6 PAST MEDICATIONS Have you ever been on any of the following medications? ANTIDEPRESSANTS ANXIETY MEDICATIONS ADHD MEDICATIONS Amitriptyline (Elavil) Alprazolam (Xanax) Adderall Notriptyline Clonazepam (Klonopin) Vyvanse Imipramine Lorazepam (Ativan) Dexedrine Clomipramine (Anafranil) Diazepam (Valium) Methylphenidate (Ritalin) Desipramine Chlordiazepoxide (Librium) Concerta Doxepin Oxazepam (Serax) Focalin Amoxapine Hydroxyzine (Vistaril) Adzenys XR (Amphetamine) Fluoxetine (Prozac) Buspirone (Buspar) Metadate (Methylphenidate) Citalopram (Celexa) Pregabalin (Lyrica) Bupropion (Wellbutrin) Escitalopram (Lexapro) Atomoxetine (Strattera) Paroxetine (Paxil) ANTIPSYCHOTICS Clonidine (Catapress) Sertraline (Zoloft) Risperidone (Risperdal) Guanfacine (Tenex; Intuniv) Fluvoxamine (Luvox) Quetiapine (Seroquel) Venlafaxine (Effexor) Olanzapine (Zyprexa) SLEEP MEDICATIONS Desvenlafaxine (Pristiq) Ziprasidone (Geodon) Trazodone Duloxetine (Cymbalta) Clozapine (Clozaril) Zolpidem (Ambien) Vortioxetine (Brintellix) Aripiprazole (Abilify) Zaleplon (Sonata) Vilazodone (Viibryd) Paliperidone (Invega) Eszopiclone (Lunesta) Bupropion (Wellbutrin) Asenapine (Saphris) Ramelteon Mirtazapine (Remeron) Iloperidone (Fanapt) Triazolam (Halcion) Phenelzineu (Nardil) Caripraszine (Vraylar) Temazepam (Restoril) Brexpiprazole (Rexulti) MOOD STABALIZERS Haloperidol (Haldol) SUBSTANCE USE TREATMENT Valproic Acid (Depakote) Fluphenazine (Prolixin) Methadone Lamotrigine (Lamictal) Pimozide (Orap) Buprenorphine (Subutex) Carbamazepine (Tegretol) Chlorpromazine (Thorazine) Disulfiram (Antabuse Oxcarbazepine (Trileptal) Perphenazine (Trilafon) Naltrexone (Vivitrol) Topiramate (Topamax Thioridazine Bupropion (Zyban) Gabapentin (Neurontin) Thiothixene (Navane) Varenicline (Chantix) Lithium Trifluoperazine (Stelazine) Acamprosate (Campra) 6
7 SUBSTANCE USE DRUG CATEGORY Do you currently use this? Comments ALCOHOL CANNABIS: Marijuana, hashish, hash oil STIMULANTS: Cocaine, crack STIMULANTS: Methamphetamine speed, ice, crank AMPHETAMINES/OTHER STIMULANTS: Ritalin, Benzedrine, Dexedrine BENZODIAZEPINES/TRANQUILIZERS: Valium, Librium, Halcion, Xanax, Diazepam, Roofies SEDATIVES/HYPNOTICS/BARBITURATES: Amytal, Seconal, Dalmane, Quaalude, Phenobarbital HEROIN STREET OR ILLICIT METHADONE OTHER OPIOIDS: Tylenol #2 & #3, 282 S, 292 S, Percodan, Percocet, Opium, Morphine, Demerol, Dilaudid HALLUCINOGENS: LSD, PCP, STP, MDA, DAT, mescaline, peyote, mushrooms, ecstasy (MDMA), nitrous oxide INHALANTS: Glue, gasoline, aerosols, paint thinner, poppers, rush, locker room OTHER: specify) 7
8 FAMILY HISTORY Please list all blood relatives who have been diagnosed with the following conditions: Depression / Major Depression /Suicide Anxiety Disorders Bipolar Disorders Schizophrenia / Schizoaffective Disorder / Psychotic Disorders Alcoholism Drug Abuse Heart disease, high blood pressure, arrhythmias Diabetes Seizure Stroke Thyroid Disorders Cancer OTHER 8
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