Psychiatric Evaluation Intake Form
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1 Psychiatric Evaluation Intake Form Patient Contact Information 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: MD NOTES: Depression/Mania/Eating/PTSD/Panic/GAD/OCD/PD/Substances 1
2 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 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 List all prior surgeries and hospitalizations for MEDICAL illnesses 2
3 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) 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 Alcohol Problems Drug problems ADHD Suicide attempts Psychiatric hospital stay What MEDICAL Problems run on one or both sides of the family? (Diabetes, High Blood Pressure, etc) 3
4 Do You Smoke or Use Tobacco Products? When was your last alcoholic drink? 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 ]= Please check the appropriate boxes that apply to you for the following substances: Never Used Age first used Last used on this approx date Age peak use Hx abuse? Current use and frequency Cocaine Amphetamine Or Speed Marijuana Diet Pills Hallucinogens (LSD,mushrooms, Mescaline) Ecstasy Diuretics Tranquilizers Pain Pills Inhalants Sleeping Pills Laxatives Cigarettes,cigars, Or tobacco PCP or Angel Dust IV Drug use Heroin GHB 4
5 Anabolic Steroids Caffeine( coffee, Tea, cola s, iced tea Benzodiazepines (xanax, valium, ativan Restoril, Librium) Other: Are you allergic to any medication or food? If so, please list below Last menstrual period (if applicable) Contraceptive method: Pharmacy: Phone #: 1. Current marital status (Check one): Single, never married Married, living together Separated Widowed Cohabiting with partner Divorced 2. Total number of marriages? How many children do you have? 3. Spouse s/partner s Name: 4. Who else lives with you? 5. How many years of formal education have you completed (years)? 5
6 6. Highest degree obtained: (Check only one) High school graduate G.E.D. 4 year college degree M.B.A./M.A./M.S./M.P.H. M.D. Junior college degree or technical school diploma J.D./LL.B. Ph.D Other 7. What best describes your current employment status? (Check one from each category a, b, & c) a. Employment Status b. Student Status c. Volunteer Status Unemployed, not looking for employment Unemployed, not looking for employment Part-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 Social security disability 8. What is your occupation? 9. Current Residence Own my house/ condo Retirement Complex/Senior Housing RENTING Apartment /Condominium 10. What is your spouse s occupation? 6
Psychiatric Evaluation Intake Form
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Psychiatric Evaluation Intake Form
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1 Client Name: Age: DOB: Today s Date Address: City: State: Zip: Home Phone: ( ) Ok to leave message? YES NO Work Phone: ( ) Ok to leave message? YES NO Current Employer (or school if a student): Gender:
New Patient Medical Questionnaire DATE:
New Patient Medical Questionnaire DATE: Patient Name: DOB: AGE: Other Physicians: Who can we thank for referring you to our practice? Pharmacy Name & Location:` Phone # CHIEF COMPLAINT What problems are
* CC* PATIENT QUESTIONNAIRE
Pain Center of Michigan *0290341CC* PATIENT QUESTIONNAIRE Patient Name Birthdate Age Home Address City State Zip Home Phone Alternate Phone Referring Physician Primary Care Physician MEDICAL HISTORY Please