Adult Intake Form. Page 1 of 5
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1 Adult Intake Form Current Symptoms Checklist: (check once for any symptoms present, twice for major symptoms) ( ) ( ) Depressed mood ( ) ( ) Racing thoughts ( ) ( ) Excessive worry ( ) ( ) Unable to enjoy activities ( ) ( ) Impulsivity ( ) ( ) Anxiety attacks ( ) ( ) Sleep pattern disturbance ( ) ( ) Increased risky behavior ( ) ( ) Avoidance ( ) ( ) Loss of interest ( ) ( ) Increased libido ( ) ( ) Hallucinations ( ) ( ) Concentration/forgetfulness ( ) ( ) Decreased need for sleep ( ) ( ) Suspiciousness ( ) ( ) Change in appetite ( ) ( ) Excessive energy ( ) ( ) ( ) ( ) Excessive guilt ( ) ( ) Increased irritability ( ) ( ) ( ) ( ) Fatigue ( ) ( ) Crying spells ( ) ( ) ( ) ( ) Decreased libido Suicide Risk Assessment Have you ever had feelings or thoughts that you didn t want to live? If YES, please answer the following. If NO, please skip to the next section. Do you currently feel that you don t want to live? How often do you have these thoughts? When was the last time you had thoughts of dying? Has anything happened recently to make you feel this way? On a scale of 1 to 10, (ten being strongest) how strong is your desire to kill yourself currently? Would anything make it better? Have you ever thought about how you would kill yourself? Is the method you would use readily available? Have you planned a time for this? Is there anything that would stop you from killing yourself? Do you feel hopeless and/or worthless? Have you ever tried to kill or harm yourself before? Do you have access to guns? If yes, please explain. Past Psychiatric History: Outpatient treatment If yes, please describe when, by whom, and nature of treatment. Reason Dates Treated By Whom Past Psychiatric Medications: If you have ever taken any of the following medications, please indicate the dates, dosage and how helpful they were (if you can t remember all the details, just write in what you do remember.) Antidepressants Dates Dosage Response/Side Effects Prozac (fluoxetine) Zoloft (sertaline) Luvox (fluvoxamine) Paxil (paroxetine) Celexa (citalopram) Lexapro (escitalopram) Effexor (venlafaxine) Cymbalta (duloxetine) Wellbutrin (bupropion) Remeron (mirtazapine) Serzone (nefazodone) Anafranil (clomipramine) Pamelor (nortrptyline) Tofranil (imipramine) Elavil (amitriptyline) Page 1 of 5
2 Mental Health Intake Form Past Psychiatric Medications (continued) Mood Stabilizers Dates Dosage Response/Side Effects Tegretol (carbamazepine) Lithium Depakote (valproate) Lamictal (lamotrigine) Topamax (topiramate) Antipsychotics/Mood Stabilizers Seroquel (quetiapine) Zyprexa (olanzepine) Geodon (ziprasidone) Abilify (aripiprazole) Clozaril (clozapine) Haldol (haloperidol) Prolixin (fluphenazine) Risperdal (risperidone) Sedative/Hypnotics Ambien (zolpidem) Sonata (zaleplon) Rozerem (ramelteon) Restoril (temazepam) Desyrel (trazodone) ADHD medications Adderall (amphetamine) Concerta (methylphenidate) Ritalin (methylphenidate) Strattera (atomoxetine) Antianxiety medications Xanax (alprazolam) Ativan (lorazepam) Klonopin (clonazepam) Valium (diazepam) Tranxene (clorazepate) Buspar (buspirone) Your Exercise Level: Do you exercise regularly? How many days a week do you get exercise? How much time each day do you exercise? What kind of exercise do you do? Family Psychiatric History: Has anyone in your family been diagnosed with or treated for: Bipolar Disorder Schizophrenia Depression Post-traumatic stress Anxiety Alcohol abuse Anger substance abuse Suicide Violence If yes, who had each problem? Has any family member been treated with a psychiatric medication? If yes, who was treated, what medications did they take, and how effective was the treatment? Page 2 of 5
3 Mental Health Intake Form Substance Use: Have you ever been treated for alcohol or drug use? If yes, for which substance(s)? If yes, where were you treated and when? How many days per week do you drink any alcohol? What is the least number of drinks you will drink in a day? What is the most number o drinks you will drink in a day? In the pas three months, what is the largest amount of alcoholic drinks you have consumed in one day? Have you ever felt you ought to cut down on your drinking or drug use? Have people annoyed you by criticizing your drinking or drug use? Have you ever felt bad or guilty about your drinking or drug use? Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover? Do you think you may have a problem with alcohol or drug use? Have you used any street drugs in the past 3 months? If yes, which ones? Have you ever abused prescription medication? If yes, which ones and for how long? Check if you have ever tried the following: Methamphetamine Cocaine Stimulants (pills) Heroin LSD or Hallucinogens Marijuana Pain killers (not as prescribed) Methadone Tranquilizer/sleeping pills Alcohol Ecstasy If yes, how long and when did you last use? How many caffeinated beverages do you drink a day? Coffee Sodas Tea Tobacco History: Have you ever smoked cigarettes? Currently? How many packs per day on average? How many years? In the past? How many years did you smoke? When did you quit? Pipe, cigars, or chewing tobacco: Currently? In the past? What kind? How often per day on average? How many years? Family Background and Childhood History: Were you adopted? Where did you grow up? List your siblings and their ages: What was your father s occupation? What was your mother s occupation? Did your parents divorce? If yes, how old were you when they divorced? If your parents divorced, who did you live with? Describe your father and your relationship with him: Page 3 of 5
4 Mental Health Intake Form Family Background and Childhood History (continued) Describe your mother and your relationship with her: How old were you when you left home? Has anyone in your immediate family died? Who and when? Trauma History: Do you have a history of being abused emotionally, sexually, physically or by neglect? Please describe when, where and by whom: Educational History: Highest grade completed? Where? Did you attend college? Where? Major? What is your highest educational level or degree attained? Occupational History: Are you currently: ( ) Working ( ) Student ( ) Unemployed ( ) Disabled ( ) Retired How long in present position? What is/was your occupation? Where do you work? Have you ever served in the military? If so, what branch and when? Honorable discharge? type of discharge? Relationship History and Current Family:: Are you currently: ( ) Married ( ) Partnered ( ) Divorced ( ) Single ( ) Widowed How long? If not married, are you currently in a relationship? If yes, how long? Are you sexually active? How would you identify your sexual orientation? ( ) straight/heterosexual ( ) lesbian/gay/homosexual ( ) bisexual ( ) transsexual ( ) unsure/questioning ( ) asexual ( ) other ( ) prefer not to answer What is your spouse or significant other s occupation? Describe your relationship with your spouse or significant other: Have you had any prior marriages? If yes, how many? How long? Do you have any children? If yes, list ages and gender: Describe your relationship with your children: List everyone who currently lives with you: Legal History: Have you ever been arrested?: Do you have any pending legal problems? Spiritual Life: Do you belong toa particular religion or spiritual group?: If yes, what is the level of your involvement? Do you find your involvement helpful during this illness, or does the involvement make things more difficult or stressful for you? Page 4 of 5
5 Mental Health Intake Form Additional Information: Is there anything else that you would like us to know? Signature: Date Guardian Signature (if under age 18): Date: Emergency Contact: Telephone #: For Office Use Only: Reviewed by: Reviewed by: Date Date Page 5 of 5
6 HEALTH HISTORY Toda y's Date, Name A ge Oate of last physical examinatio ' Birthdate GENERAL Chills Depression Dizziness Fever Forgetfulness Headache Loss of sleep Loss of weight Numbness Sweats MUSC Pain, weakness, numbness in: Arms Back Feet Hands Hips Legs Neck Shoulders Blood in urine Frequent Lack of bladder control Painful AIDS Alcoholism Anemia Anorexia Appendicitis Asthma Bleeding Disorders Breast Lump Bronchitis Bulimia Cancer Cataracts OTHER MEDICATIONS Pharma Name EYE, EAR, NOSE, THROAT Bleeding gums Blurred vision Crossed eyes swallowing Double vision Earache Ear discharge Hay fever Hoarseness Loss of Nosebleeds Persistent cough Ringing in ears Sinus problems Vision - Flashes Vision - Halos Appetite poor Bloating Bowel changes Constipation Diarrhea Excessive hunger Excessive thirst Gas Hemorrhoids Indigestion Nausea Rectal bleeding Stomach pain Vomiting Vomiting blood ' CARDIOVASCULAR Chest pain High blood pressure Irregular beat Low pressure Poor circulation Rapid beat Swelling of ankles Varicose veins SKIN Bruise easily Hives Itching Change in moles Rash Chemical Dependency Chicken Pox Diabetes Emphysema Epilepsy Glaucoma Goiter Gonorrhea Gout Disease Hepatitis Hernia.. ;,,.. ; Phone MEN only Breast lump Lump in testicles Penis discharge Sore on penis Sore on penis WOMEN only Abnormal Pap Smear Bleeding Breast lump Extreme menstrual pain Hot Nipple discharge Painful Vaginal discharge Date of last menstrual period Date of last Pap Smear Have you had a mammogram? Oscars Are you pregnant? High Cholesterol HIV Positive Kidney Disease Liver Disease Measles Migraine Headaches Miscarriage Mononucleosis Multiple Sclerosis Mumps Pacemaker Pneumonia Polio Prostate Problem Care Rheumatic Fever Scarlet Fever Stroke Suicide Attempt Thyroid Problems Tonsillitis Tuberculosis Typhoid Fever Ulcers Vaginal Infections Venereal Disease _
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8 TRAUMA HISTORY Prior to your 18th birthday: Did a parent or other adult in the household often or very often Swear at you, insult you, put you down, or humiliate you? or Act in a way that made you afraid that you might be physically hurt? Did a parent or other adult in the household often or very often Push, grab, slap, or throw something at you? or Ever hit you so hard that you had marks or were injured? Did an adult or person at least 5 years older than you ever Touch or fondle you or have you touch their body in a sexual way? or Attempt or actually have oral, anal, or vaginal intercourse with you? Did you often or very often feel that No one in your family loved you or thought you were important or special? or Your family didn t look out for each other, feel close to each other, or support each other? Did you often or very often feel that You didn t have enough to eat, had to wear dirty clothes, and had no one to protect you? or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it? Were your parents ever separated or divorced? Was your mother or stepmother: Often or very often pushed, grabbed, slapped, or had something thrown at her? or Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? or Ever repeatedly hit over at least a few minutes or threatened with a gun or knife? Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs? Was a household member depressed or mentally ill, or did a household member attempt suicide? Did a household member go to prison?
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