Dear Applicant: Complete ONLY the individual sections where there is a current or recent concern.

Transcription

1 Dear Applicant: Thank you for your interest in becoming a patient at the Children s Psychiatric Services of South Texas (CPSOST). In order to provide you with the best care, it is important for our medical team to have the information requested in the following pages of the Health History. Complete ONLY the individual sections where there is a current or recent concern. We look forward to having the opportunity to serve you. If you need assistance with completing the Health History, or if you have any questions, please contact us at (361) Please submit the completed Health History Form by mailing / faxing to: Corpus Christi, Texas, Fax Electronic Communication: If you would like to use communication, please provide your address. Please note that we cannot send private medical information by due to privacy concerns. If the patient is a minor, please list the address of the parent/legal guardian. Patient Parent/Guardian How did you hear about CPSOST? Family Member Friend Internet - if so: Professional Referral (please provide specific information on the next page) 1

2 Health History Demographics PATIENT INFORMATION NAME: Last, First Middle Initial ADDRESS: Number Street Apt. City: State: ZipCode: DATE OF BIRTH (DOB): / / GENDER: M F Is the patient a minor? Yes No WEIGHT: lbs. Is the patient the Guarantor? Yes No Phone: ( ) - (if different than Guarantor) Complete the following information if the patient is a minor: Mother s Name: Father s Name: or Legal Guardian s Name: 2

3 EMERGENCY CONTACTS NAME: Parent Legal Guardian Spouse Other: PHONE: ( ) - 2. NAME: Parent Legal Guardian Spouse Other: PHONE: ( ) - GUARANTOR INFORMATION NAME: (Last, First, Middle Initial) Patient Parent Legal Guardian Spouse Other: ADDRESS: Number Street Apt. City: State: ZipCode: Home: ( ) - Work ( ) - Cell: ( ) - PROFESSIONAL REFERRAL: NAME: PROF. TITLE: Phone: ( ) - 3

4 Insurance: Medicare? Yes No Medicaid? Yes No TRICARE? Yes No StarPlus? Yes No Plan: Other? Yes No Member ID: Group: Insurance Company: Address: City: State: Zip: - Phone: FINANCIAL RESPONSIBILITY I understand that all professional services are charged to the patient, and are due and payable on the date that services are rendered unless other arrangements have been made in advance with the financial counselor. I agree to pay all such charges in full immediately upon presentation of the appropriate statement. Signed: Date: / / Guarantor 4

5 PATIENT MEDICAL HISTORY FORM Date: / / Name: Last First M.I. Briefly describe your present symptoms: Birthdate: / / Please describe the following: Sleep: hours/night Any problems with: Difficulty falling asleep Waking up in the middle of the night Nightmares Restless Sleep Appetite: Same as before Decreased Increased Dieting Any weight changes: Please check all that apply: Sadness Insomnia Panic Attacks Obsessions/Compulsions Hopelessness Guilt Racing Thoughts Anxiety Fatigue Withdrawal / Decrease Socialization Decrease Interest Levels Irritability / Easy Anger Aggression Behavioral Problems Impulsivity Grief / Loss Uncontrolled Fear / Phobia Nightmares Recollection of Trauma Worthlessness Eating Disorder Chronic Pain Issues General Overwhelming Stress Thoughts of Hurting Self Active Plan to Hurt Myself Hallucinations Difficulty With Work / School / Family Rapid Weight Loss / Weight Gain Difficulty motivating myself to do basic responsibilities Memory Impairment Personality Changes Mania (decrease sleep accompanied by high energy or agitation, impulsivity, increase in drive to do activity) PSYCHIATRIC HISTORY Have you ever seen a specialist/psychiatrist? Yes No If yes, please fill in below: Name of Physician / Clinic Duration of Treatment Location (City / State) Reason for Treatment Have you ever seen a primary care doctor for mood issues? Yes No If so, please explain when and for what reason: 5

6 Have you ever been hospitalized in a psychiatric facility? Yes No If so, please fill below: Name of Physician / Clinic Duration of Treatment Location (City / State) Reason for Treatment What diagnoses have you been treated for: Major Depression Anxiety Disorder Obsessive/Compulsive Disorder Bipolar Disorder Schizophrenia Autism Eating Disorder Personality Disorder ADHD/ADD Post-traumatic stress disorder Other: Please check any that apply to your psychiatric history: History of suicidal ideation: Yes No Suicide attempts: Yes No If above checked please specify: (Number of suicide attempts in lifetime.) Any hospitalization as a result? Yes No History of aggressive/threatening behavior: Yes No History of self-injury/cutting: Yes No Any past history of trauma: Childhood physical abuse Childhood emotional/verbal abuse Childhood sexual abuse Childhood exposure to domestic violence Combat Trauma Witness to death of loved one Survivor of suicide Exposure to potentially deadly/deadly accident Exposure to fire Exposure to natural disaster Partner physical/emotional/verbal abuse Stranger Rape/Assault Rape/Assault by Family Member Exposure to War Early Parental Loss Neglect in Childhood Forced Prostitution Other: 6

7 PAST MEDICAL HISTORY: Do you now or have you had: Diabetes Heart Murmur Crohn s Disease High Blood Pressure Pneumonia Colitis High Cholesterol Pulmonary Embolism Anemia Hypothyroidism Asthma Jaundice Goiter Emphysema Hepatitis Cancer 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): Have you had any surgeries in the past (please list procedure and date): FAMILY HISTORY Problem Mother Father Grandmother Depression Anxiety Obsessive Compulsive Anger / Aggression Bipolar disorder Schizophrenia Completed Suicide Drug Abuse Dementia Autism Hospitalized for above Grandfather Sister Brother Uncle / Aunt Children 7

8 Any of your family members have the medical conditions below: If so, please specify who below 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/Peptic ulcer Leukemia Epilepsy (seizures) Rheumatic fever Psoriasis Cataracts Tuberculosis Angina Kidney disease HIV / AIDS Heart problems Kidney stones Please specify which family member has the above condition and any other condition(s) not listed above: SUBSTANCE ABUSE HISTORY Are you a smoker? Yes No If yes, how many packs to you smoke? Any attempts to quit? If you quit using, how long? Do you consume alcohol? Yes No How often do you drink? Weekly / week Monthly / month Rarely Quit Drinking (specify last usage) Specify amount you drink in each sitting: Do you have a history of Substance Abuse? Yes No Have you ever attended rehab? Yes No If yes, please state when and for treatment of what: Other substances used: Substance Quantity Used Frequency of Use Quit (Y/N) Last Used 8

9 CURRENT MEDICATIONS Drug allergies: Yes No To what medication? What reaction did you have? Please list any medications that you are now taking. Include non-prescription medications and vitamins or supplements: Medication (Brand/Generic Name) Dose Type (Liquid, Tablet, Capsule, Injection) Frequency Reason for taking Date Started Physician 9

10 Have you tried any psychiatric medications for mood / anxiety / sleep before? Yes No If so, briefly list some that you recall: Was there one or more medications (including combinations) that were particularly beneficial for you: SOCIAL HISTORY If patient is a child / adolescent: Patient lives with / raised by: Any Siblings? Are Parents Divorced? Yes No If yes, specify arrangement: Any step-parents? Yes No If patient is an adult: Relationship status: Single Married Divorced Widowed Life/Serious Partner Are you happy in your relationship? No Yes Describe your relationship satisfaction: N/A Very Satisfied Somewhat Satisfied Dissatisfied Any children? No Yes Specify Name / Sex / Age of children below: Name Son/Daughter Biologic/Step/Adopted Age EDUCATION HISTORY: Currently in school: (specify) Less than a high school education Graduated from high school GED Obtained (specify highest grade completed) Associates Degree College Degree Some College Professional Degree Technical Degree Master s Degree EMPLOYMENT STATUS: Full-time Part-time Unemployed Retired Disabled Homemaker Occupation: Employer: How long have you had this job: Any other pertinent information that you feel is important to your treatment: Have your child s teacher(s) fill out the attached questionnaire 10

11 Teacher s Professional Judgment Questionnaire Child s Name Teacher s Name Date Below are a series of questions which ask for your professional judgment about this child. There are no right or wrong answers, rather we are trying to better understand how this child acts in your classroom Not at Just a Pretty Very all little Much Much MORNING Do you think this child is hyperactive? Do you think this child is inattentive? Is this child easily distracted in the classroom? Does this child s behavior escalate in a group setting versus a one on one setting? Does this child work at an inconsistent pace? Does this child need more supervision at the start of a task/project Does this child talk out of turn? Is this child s desk poorly organized? Does this child record assignments inaccurately? Does this child frequently not turn in homework assignments? Does this child have difficulty in an academic area? If yes which academic areas: AFTERNOON Do you think this child is hyperactive? Do you think this child is inattentive? Is this child easily distracted in the classroom? Does this child s behavior escalate in a group setting versus a one on one setting? Does this child work at an inconsistent pace? Does this child need more supervision at the start of a task/project Does this child talk out of turn? Is this child s desk poorly organized? Does this child record assignments inaccurately? Does this child frequently not turn in homework assignments? Does this child have difficulty in an academic area? If yes which academic areas: 11