PATIENT IDENTIFICATION: Name: First Appointment Date: Birth Date: Address: City State Zip Home Phone #: Work #: Cell #: REFERRAL SOURCE: Referred By:
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1 Andrew E. Leifer, M.D., P.C Bergen Parkway, Suite 211 Evergreen, Colorado General Adult Psychiatry Outpatient and Hospital Care Medical Consultation-Liaison Service Telephone (303) Fax (303) ADULT INTAKE QUESTIONNAIRE In order to evaluate you fully, please fill out the following questionnaire to the best of your ability. I realize there may be information that you do not remember or cannot access; please do the best you can. Use the backside for additional space. Thank you! PATIENT IDENTIFICATION: Name: First Appointment Date: Birth Date: Age: Sex: M / F Marital Status: S / M/ W / D / Sep. Religion (opt.): Race (opt.): # Children: Address: City State Zip Home Phone #: Work #: Cell #: REFERRAL SOURCE: Referred By: Referral Address: Phone # : Do I have your permission to release information to the referring professional when it is appropriate? Yes No PRIMARY CARE PHYSICIAN INFORMATION: PCP Name: PCP Address: Phone # : Do I have your permission to release information to the referring professional when it is appropriate? Yes No PURPOSE OF THE CONSULTATION: (Please give a brief summary of the main problems.) WHY DID YOU SEEK THE EVALUATION AT THIS TIME?: Page 1 of 6.
2 PRIOR ATTEMPTS TO CORRECT PROBLEMS PRIOR PSYCHIATRIC HISTORY: (Please include contact with other professionals, medications, types of treatment, etc.) MEDICAL HISTORY: Current medical problems/medications: Past medical problems/medications: Other doctors/clinics seen regularly: Any history of head trauma? (describe): Ever any seizures or seizure like activity? Any periods of spaciness or confusion? Prior Hospitalizations (place, cause, date, outcome): Prior abnormal lab tests, X-rays, EEG, etc.: Allergies/drug intolerances (describe): Present Height: Present Weight: CURRENT LIFE STRESSES: (include anything that is currently stressful for you, examples include relationships, job, school, finances, children) FAMILY HISTORY: Family Structure (with whom do you currently live, add other info as necessary): Page 2 of 6.
3 Significant Developmental Events (include marriages, separations, divorces, deaths, traumatic events, losses, abuse etc.): Current Marital or Relational Situation/Satisfaction: History of Past Marriages: Natural Mother's History: age Outside work: School; highest grade completed: Learning problems (specify): Behavior problems (specify): Marriages: _ Medical Problems: Childhood atmosphere (family position, abuse, illnesses, etc) : Has mother ever sought psychiatric treatment? Yes No If yes, for what purpose? Mother's alcohol/drug use history: Have any of mother's blood relatives ever had any learning problems or psychiatric problems including such things as alcohol/drug abuse, depression, anxiety, suicide attempts, psychiatric hospitalizations? (specify): Natural Father's History: age Outside work: School; highest grade completed: Learning problems (specify): Behavior problems (specify): Marriages: _ Medical Problems: Childhood atmosphere (family position, abuse, illnesses, etc) : Page 3 of 6.
4 Has father ever sought psychiatric treatment? Yes No If yes, for what purpose? Father's alcohol/drug use history: Have any of father's blood relatives ever had any learning problems or psychiatric problems including such things as alcohol/drug abuse, depression, anxiety, suicide attempts, psychiatric hospitalizations? (specify): Siblings (names, ages, problems, strengths, relationship to yourself): Children (names, ages, problems, strengths): EDUCATIONAL HISTORY: Last grade completed: Last school attended: Average grades received: Any academic problems? Learning strengths: Any behavior problems in school? What would your teachers have said about you? EMPLOYMENT HISTORY: (summarize jobs you've had, list most favorite and least favorite): Any work-related problems? What would your employers or supervisors have said about you? Page 4 of 6.
5 MILITARY HISTORY: LEGAL HISTORY: (past or present, include DUI history) ALCOHOL AND DRUG HISTORY: (Please list age started and types of substances used through the years and any current usage. Also, describe how each of these substances made you feel; what benefit you got from them). This includes alcohol (hard liquor, beer, wine), marijuana or hash, prescription tranquilizers or sleeping pills, inhalants (glue, gasoline, cleaning fluids, etc.), cocaine or crack, amphetamines, crank or ice, steroids, opiates (heroin, codeine, morphine or other pain killers), barbiturates, hallucinating drugs (LSD, mescaline, mushrooms), PCP. Ever experience withdrawal symptoms from alcohol or drugs? Has anyone told you they thought you had a problem with drugs or alcohol? Have you ever felt guilty about your drug or alcohol use? Have you ever felt annoyed when someone talked to you about your drug or alcohol use? Have you ever used drugs or alcohol first thing in the morning? Caffeine use per day (caffeine is in coffee, tea, sodas& chocolate): Nicotine use per day, past and present, (nicotine is in cigarettes, cigars& tobacco chew): Cultural/Ethnic Background (opt.): Page 5 of 6.
6 CURRENT RELATIONSHIPS: Describe your relationships with friends: Describe yourself: What are your goals in seeking this consultation? What do you hope to gain? Page 6 of 6.
problems/medications: Current supplements/vitamins/herbs: Past medical problems/medications: Other doctors/clinics seen regularly:
Main Purpose of the consultation (Please give a brief summary of the main problems) What happened to make you seek evaluation at this time? MEDICAL HISTORY Current medical Prior Attempts to correct the
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Name: Gender: male female Age: Date of birth: / / Preferred phone: cell home work other. Alternate phone: cell home work other.
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Dear Student: Thank you for taking the 2017 CMS Student survey! This survey collects information about what students think about alcohol, drugs, and their school. It will only take about 20-25 minutes
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Illinois State University (Online)
Carbondale, IL 62901 Number of Surveys = 701 Page 1 of 8 Illinois State University (Online) CORE ALCOHOL AND DRUG SURVEY LONG FORM - FORM 194 EXECUTIVE SUMMARY The Core Alcohol and Drug Survey was developed
Address: Spouse/Partner Name: Phone: Address:
Adult Wellness Assessment Please take a few minutes to fill out this form. The information will be helpful in better understanding your individual needs and situation. Thank you. Personal Information Name:
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