Richard Heidenfelder M.D. Child, Adolescent and Adult Psychiatry 447 9th Ave San Diego, CA

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*We are not accepting any New Patients who are currently taking any controlled pain medications *We are *Note: not completion accepting of the any following New Patients paperwork who and Initial are Screening currently Exam taking does controlled not guarantee pain acceptance medications. Richard Heidenfelder M.D. Child, Adolescent and Adult Psychiatry 447 9th Ave San Diego, CA 92101 DrH.Office447@Gmail.com Request for Treatment Form In order to schedule a Medi-Cal New Patient Evaluation please complete this Request for Treatment Form and submit it in person at your office New Patient during between Screening our 2-4 normal p.m. Appointment. Tues office or Thurs. hours. After submission your information will be reviewed by Dr. Heidenfelder and your New Patient Evaluation appointment will be formally scheduled. Name Date Date of Birth Primary Care Physician Address City: Zip: Home phone # Cell phone # Email Parent/Guardian s Name Social Security # Medi-Cal ID # Other Insurance Do you give permission for ongoing regular updates to be provided to your primary care physician? Current Therapist/Counselor Therapist's Phone What are the problem(s) for which you are seeking help? 1. 2. 3. What are your treatment goals?

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 ( ) Increase risky behavior ( ) Avoidance ( ) Loss of interest ( ) Increased libido ( ) Hallucinations ( ) Concentration/forgetfulness ( ) Decrease 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? ( ) Yes ( ) No. 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? ( ) Yes ( ) No 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 Medical History: Allergies Current Weight Height

List ALL current prescription medications and how often you take them: (if none, write none) Medication Name Total Daily Dosage Estimated Start Date Current over-the-counter medications or supplements: Current medical problems: Past medical problems, nonpsychiatric hospitalization, or surgeries: Have you ever had an EKG? ( ) Yes ( ) No If yes, when. Was the EKG ( ) normal ( ) abnormal or ( ) unknown? Personal and Family Medical History: You Family Thyroid Disease ---------------------- ( ) ( ) Anemia-------------------------------- ( ) ( ) Liver Disease ------------------------- ( ) ( ) Chronic Fatigue ----------------------- ( ) ( ) Kidney Disease ----------------------- ( ) ( ) Diabetes -------------------------------- ( ) ( ) Asthma/respiratory problems ------ ( ) ( ) Stomach or intestinal problems --- ( ) ( ) Cancer (type) ------------------------ ( ) ( ) Fibromyalgia -------------------------- ( ) ( ) Heart Disease ------------------------- ( ) ( ) Epilepsy or seizures ------------------ ( ) ( ) Chronic Pain ------------------------- ( ) ( ) High Cholesterol -------------------- ( ) ( ) High blood pressure------------------ ( ) ( ) Head trauma -------------------------- ( ) ( )

Liver problems ----------------------- ( ) ( ) Other ---------------------------------- ( ) ( ) Past Psychiatric History: Outpatient treatment ( ) Yes ( ) No If yes, Please describe when, by whom, and nature of treatment. Reason Dates Treated By Whom Psychiatric Hospitalization ( ) Yes ( ) No If yes, describe for what reason, when and where. Reason Date Hospitalized Where 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). Dates Dosage Response/Side-Effects Antidepressants Prozac (fluoxetine) Zoloft (sertraline) 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) Mood Stabilizers Tegretol (carbamazepine)

Lithium Depakote (valproate) Lamictal (lamotrigine) Topamax (topiramate) Past Psychiatric medications (continued) Antipsychotics/Mood Stabilizers Dates Dosage Response/Side-Effects 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) Other

Family Psychiatric History: Has anyone in your family been diagnosed with or treated for: Bipolar disorder ( )Yes ( )No Schizophrenia ( )Yes ( )No Depression ( )Yes ( )No Post Traumatic Stress ( )Yes ( )No Anxiety ( )Yes ( )No Alcohol abuse ( )Yes ( )No Anger ( )Yes ( )No Other substance abuse ( ) Yes ( ) No Suicide ( )Yes ( )No Violence ( )Yes ( )No Check if you have ever tried the following: Yes No If yes, how long and when did you last use? Methamphetamine ( ) ( ) Cocaine ( ) ( ) Stimulants (pills) ( ) ( ) Heroin ( ) ( ) LSD or Hallucinogens ( ) ( ) Marijuana ( ) ( ) Pain killers (not as prescribed) ( ) ( ) Methadone ( ) ( ) Tranquilizer/sleeping pills ( ) ( ) Alcohol ( ) ( ) Ecstasy ( ) ( ) Other ( ) ( ) Signature Date Guardian Signature (if under age 18) Date Emergency Contact Telephone # T *Note: The New Patient Screening Appointment is for screening purposed purposes ONLY and is not a formal Initial Evaluation. Upon submission and review of your information you will be scheduled for a full Initial Evaluation at a subsequent date-typically within 2 weeks. * Submission of the Treatment Request Form does not guarantee acceptance as a patient with our practice.

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