Past Psychiatric History: What issues or symptoms bring you to this practice? When did these symptoms start? Are the symptoms constant or intermittent? List any previous psychiatric conditions you have been diagnosed with Name of previous psychiatrist(s) and years seen Name of current or previous counselor/ therapist(s) and years seen List of previous psychiatric hospitalization(s) with dates and reasons for admission(s) Have you ever attempted suicide and if so, when and how? Have you ever received ECT (shock treatment)? Have you ever experienced problems with the following? YES NO YES NO Extreme Depressed Mood Hallucinations Erratic Mood Swings Paranoia Rapid Speech Self-Mutilation/Cutting Behaviors Impulsivity Body Image Issues Racing Thoughts Intrusive Obsessive Thoughts/Repetitive Behaviors Panic Attacks Binge Eating Extreme Anxiety Purging/Food Restricting Sleep Disturbances Anger/Irritability/Aggression Issues Family Psychiatric History: Check all that apply and identify any family members with the disorders below: Depression Bipolar Disorder (Manic Depression) Post-Traumatic Stress Disorder Panic Attacks/Anxiety Obsessive Compulsive Disorder Schizophrenia Substance Abuse Alcohol Abuse Eating Disorders Autism Attempted or Completed Suicide YES FAMILY MEMBER(S) COMMENTS/SPECIFICS Patient Name: MRN: Date: Page 1
Medical Information: CURRENT MEDICATIONS AND DOSAGES (Including Over-the-Counter and Herbal Medications): MEDICATION ALLERGIES: Females Only: Is there any chance you are currently pregnant? Females Only: Current Birth Control Method Used: Primary Care Provider: Referring Provider: Patient and Family Medical History: Anemia/Blood Disorders Cancer Diabetes Migraines Hepatitis/Liver Disorder Heart Disease Hypertension Lung Disease HIV Seizures/Neurologic Illnesses Serious Head Injury/Concussion Thyroid Disease Other Hospitalizations/Surgeries: PATIENT FAMILY MEMBER(S) COMMENTS/SPECIFICS DATE WHERE WHY Patient Name: MRN: Date: Page 2
Background: Where were you born? Who raised you? Have you lived in a group home or in foster care? Number of siblings and their ages: Do you have a guardian or a payee? What is your marital status? If you are not married, are you currently in a romantic relationship? How long have you been in this relationship/marriage? On a scale of 1-10 (10 being the best) how would you rate the current quality of your marriage/relationship? Number of children and their ages: What are your current living arrangements? Highest education level you completed: Current employer/position: Are you happy at your current position? Please list any work related stressors Who do you turn to for emotional support? Do you consider yourself a religious person? If yes, what is your Faith? Have you ever been a victim of any form of abuse? Have you ever had any legal problems? If so, what type/when? Do you have a history of violent behavior? Do you have access to firearms? Describe any recent significant life changes or stressors: What do you consider your strengths? What are your goals for psychiatric treatment? Substance Use History: Have you ever abused or been dependent on any illicit drugs, prescription drugs or alcohol? If yes, which drug(s)? First Used? Last Used? Highest Amount Used? Current Amount Used? History of rehab/detox: Previous social/legal consequences to substance use: Patient Name: MRN: Date: Page 3
Psychiatric Medication History: ADHD/Psycho-Stimulants: o Adderall (amphetamine+ dextroamphetamine) o Dexedrine (dextroamphetamine) o Focalin (dexmethylphenidate) o Intuniv/Tenex (guanfacine) o Nuvigil (armodafinil) o Provigil (modafinil) o Ritalin/Concerta/Daytrana/Metadate (methylphenidate) o Strattera (atomoxetine) o Vyvanse (lisdexamfetamine) SNRI Antidepressants: o Cymbalta (duloxetine) o Effexor (venlafaxine) o Fetzima (levomilnacipran ER) o Pristiq (desvenlafaxine) Tricyclic Antidepressants: o Anafranil (clomipramine) o Asendin (amoxapine) o Elavil (amitriptyline) o Norpramin (desipramine) o Pamelor (nortriptyline) o Sinequan (doxepin) o Surmontil (trimipramine) o Tofranil (imipramine) o Vivactil (protriptyline) Please check all medications you have taken. Cognitive Enhancers: o Aricept (donepezil) o Axona (caprylidene) o Exelon (rivastigmine) o Namenda (memantine) o Razadyne (galantamine) Combination Antidepressant/Antipsychotics: o Symbyax (olanzapine + fluoxetine) MAOI Antidepressants: o Emsam (selegiline) o Marplan (isocarboxazid) o Nardil (phenelzine) o Parnate (tranylcypromine) SSRI Antidepressants: o Celexa (citalopram) o Lexapro (escitalopram) o Luvox (fluvoxamine) o Paxil/Pexeva (paroxetine) o Prozac (fluoxetine) o Viibryd (vilazodone) o Zoloft (sertraline) Other Antidepressants: o Brintellix/Trintellix (vortioxetine) o Maprotiline o Remeron (mirtazapine) o Serzone (nefazodone) o Wellbutrin/Zyban (bupropion) Drug Dependence: o Antabuse (disulfiram) o Campral (acamprosate) o Chantix (varenicline) o Dolophine (methadone) o Suboxone (buprenorphine + naloxone) o Subutex (buprenorphine) o Vivitrol (naltrexone) Patient Name: MRN: Date: Page 4
Mood Stabilizers/Anticonvulsants: o Depakote (valproic acid) o Gabitril (tiagabine) o Keppra (levetiracetam) o Lamictal (lamotrigine) o Eskalith/Lithobid (lithium) o Lyrica (pregabalin) o Neurontin (gabapentin) o Tegretol/Equetro (carbamezepine) o Topamax (topiramate) o Trileptal (oxcarbazepine) o Zonegran (zonisamide) Antipsychotics: o Abilify (aripiprazole) o Clozaril (clozapine) o Fanapt (lloperidone) o Geodon (ziprasidone) o Haldol (haloperidol) o Invega (paliperidone) o Latuda (lurasidone) o Loxitane (loxapine) o Mellaril (thioridazine) o Moban (molindone) o Navane (thiothixene) o Orap (pimozide) o Prolixin (fluphenazine) o Rexulti (brexpiprazole) o Risperdal (risperidone) o Saphris (asenapine) o Seroquel (quetiapine) o Stelazine (trifluoperazine) o Thorazine (chlorpromazine) o Trilafon (perphenazine) o Zyprexa (olanzapine) Long-Acting Injectables: o Abilify Maintena o Haldol Decanoate o Invega Sustenna o Invega Trinza o Prolixin Decanoate o Risperdal Consta o Zyprexa Relprevv Sleep Medications: o Ambien (zolpidem) o Belsomra (suvorexant) o Benadryl (diphenhydramine) o Dalmane (flurazepam) o Lunesta (eszopiclone) o Prosom (estazolam) o Restoril (temazepam) o Rozerem (ramelteon) o Somnote (chloral hydrate) o Sonata (zaleplon) o Desyrel/Oleptro (trazodone) o Xyrem (sodium oxybate) Tranquilizers/Anti-Anxiety: o Ativan (lorazepam) o BuSpar (buspirone) o Halcion (triazolam) o Inderal (propranolol) o Klonopin (clonazepam) o Librium (chlordiazepoxide) o Serax (oxazepam) o Tenormin (atenolol) o Tranxene (clorazepate) o Valium (diazepam) o Vistaril (hydroxyzine) o Xanax (alprazolam) Weight Loss Medications: o Adipex (phenteramine) o Meridia (sibutramine) Other: o Clonidine (catapres) o Deplin (l-methylfolate) o Ketalar (ketamine) o Levothyroxine (thyroxine) o N-Acetylcysteine o Savella (milnacipran) Patient Name: MRN: Date: Page 5