Welcome and thank you for choosing University of Florida Physicians!

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

New Patient Questionnaire

PSYCHIATRY INTAKE FORM

Medications and Children Disorders

Review of Psychotrophic Medications. (An approved North Carolina Division of Health Services Regulation Continuing Education Course)

Happy Daisy Ltd. New Client intake Form. What are the issues for which you are seeking care?

Mental Health Intake Form

Judges Reference Table for the March 2016 Psychotropic Medication Utilization Parameters for Foster Children

Mental Health Intake Form

Schedule FDA & literature based indications

Adult Initial Assessment / Patient Questionnaire Page 1

Steps for Initiating Electroconvulsive Therapy Treatment

TRANSCRANIAL MAGNETIC STIMULATION & BRAIN MUSIC THERAPY

Appendix: Psychotropic Medication Reference Tables

Dealing with a Mental Health Crisis

USF Health Psychiatry Clinic. New Patient Questionnaire Adult

A Brief Overview of Psychiatric Pharmacotherapy. Joel V. Oberstar, M.D. Chief Executive Officer

Guide to Psychiatric Medications for Children and Adolescents

Ohio Psychotropic Medication Quality Improvement Collaborative. Minds Matter. Toolkit. for You and Your Family. This is the property of

IMPORTANT NOTICE. Changes to dispensing of some Behavioral Health Medications for DC Healthcare Alliance members

NEW PATIENT INTAKE FORM

Psychiatric Medications. Positive and negative effects in the classroom

LAGUNA BEHAVIORAL Crown Valley Parkway, Suite 140 Phone: (949) Laguna Niguel, CA Fax: (949)

Overview and Update on Current Psychopharmacological Medications, Including New Medications in Clinical Trials

MO Medicaid Foster Care Drugs FY10-FY14

4/2/13 COMMON CLASSES OF MEDICATIONS. Child & Adolescent Behavioral Medicine & Medication Therapies. Behavioral Medicine & Medication Therapies

Medically Accepted Indications for Pediatric Use of Psychotropic Medications by

Germantown Private Psychiatry PLLC

ELEMENTAL CENTER MENTAL HEALTH INTAKE FORM

Patient History Form

Mental Illness. Doreen L. Rasp, APN, FNP, PMHNP Advanced Behavioral Counseling

Ohio Psychotropic Medication Quality Improvement Collaborative. Minds Matter. Toolkit. for Youth and Caregivers. This is the property of

med ed Copyright All rights reserved. No part of this publication can be reproduced without prior written consent of the authors.

Creating Partnerships. Laine Young-Walker, MD

Supplement: Tables and Figures

Treating Disruptive Behavior Disorders in Children and Teens. A Review of the Research for Parents and Caregivers

CHILD / ADOLESCENT HISTORY

Psychiatric Illness. In the medical arena psychiatry is a fairly recent field A challenging field Numerous diagnosis

Psychotropic Medications Archana Jhawar, PharmD, BCPP Clinical Faculty of UIC Pharmacy Practice Clinical Psychiatric Pharmacist Jesse Brown VA

CENPATICO INTEGRATED CARE BEHAVIORAL HEALTH DRUG LIST BY DRUG NAME. Use Brand Only

Mental Health Medications. National Institute of Mental Health. U.S. Department of HealtH and HUman ServiceS National Institutes of Health

Psychotropic Medications in Children and Adolescents: Guide for Use and Monitoring

Child & Adolescent Patient History Questionnaire

COUNSELING ASSESSMENT REFERRAL AND BACKGROUND INFORMATION (Adult Form) cell telephones/fax #s/ addresses: (Spouse): (Emergency Contact):

OBJECTIVES PSYCHOTROPIC MEDICATIONS WHAT IS PSYCHOTROPIC MEDICATION?

CENPATICO INTEGRATED CARE BEHAVIORAL HEALTH DRUG LIST BY DRUG CLASS

Study Guidelines for Quiz #1

U T I L I Z A T I O N E D I T S

Treat mood, cognition, and behavioral disturbances associated with psychological disorders. Most are not used recreationally or abused

Child & Adolescent Psychiatry (a brief overview)

HCA BHS Prescribing Guidelines Committee - Approved Medications 2012

Depression. University of Illinois at Chicago College of Nursing

FROM MEDICATION TO MINDFULNESS: NEW INSIGHTS INTO THE WORLD OF ANXIETY

PSYCHIATRIC DRUGS. Mr. D.Raju, M.pharm, Lecturer

Francine Grevin, Psy.D. Licensed Clinical Psychologist PSY South Main Plaza, Suite 225 Telephone (925) CHILD HISTORY FORM

POSITIVE YOUTH CONCEPTS Child and Adolescent Therapy 24 Front Street, Suite 302 Exeter, NH

Use Brand Only. Preferred Drug Status PRIOR AUTHORIZATION REQUIRED

5151 Research Dr NW Huntsville, AL Ph Fax

Before you try another medication, try asking your DNA

PSYCHIATRIC HISTORY 6. Are you currently seeing a therapist? (Name & contact phone#)

AAA. add dan campbell artwork cats? Report #12 Changes in Medication Use over Time in Adolescents and Adults with Autism Spectrum Disorders

Child Intake Form. Guardian Information Section. Emergency Contact: Relationship: Phone: Insurance Information Section

Patients considering TMS Therapy

Depression and Anxiety. What is Depression? What is Depression? By Christopher Okiishi, MD Spring Not just being sad A syndrome of symptoms

Patients considering TMS Therapy

New Patient Self-Report Questionnaire. Demographics. Name (last, first, mi): Age: Date of Birth: Address: Home Phone: Work Phone: Cell:

Introductory discussion

8/15/17. Managing Psychiatric Conditions in Primary Care Beyond the Basics. Speaker s Biography. Situation

Attention: Behavioral Health Providers, Pharmacists and Prescribers N.C. Medicaid and N.C. Health Choice Preferred Drug List Changes - UPDATE

Short Clinical Guidelines: General Anxiety Disorder (GAD)

Change Your Brain, Change Your Life. The Breakthrough Program for Conquering Anxiety, Depression, Obsessiveness, Anger, and Impulsiveness

Adult Intake Form. Page 1 of 5

Psychiatric Medication Guide

AHCCCS BEHAVIORAL HEALTH DRUG LIST EFFECTIVE OCTOBER 1, 2016

Class: Treatment with Medication:

Child/ Adolescent Questionnaire

AD/HD is a mental disorder, and it often lasts from

Autism: Improving Health Care Outcomes

Children s Hospital Of Wisconsin

LifePath Systems Medication and Laboratory Formulary

PATIENT FACE SHEET PATIENT NAME: PATIENT DOB: PATIENT PHONE #: INSURANCE: MEMBER ID: GROUP NUMBER: PATIENT ADDRESS

CHILD & ADOLESCENT PSYCHIATRY ALERTS, VOLUME XIV, 2012 INDEX

All formulary medications available in generic form are supplied in generic form. Requests for brand name preparations must get prior authorization.

Thank you for choosing Pine Rest Christian Mental Health Services. We look forward to providing services to you.

Psychiatric Evaluation Intake Form

ALAMEDA COUNTY BEHAVIORAL HEALTH CARE SERVICES MEDICATION FORMULARY

Psychiatric Issues in Huntington s Disease

DEPRESSION. Men and women of all ages, races, and economic levels can have depression. It occurs more often in women.

Address: Spouse/Partner Name: Phone: Address:

Medications for Anxiety & Behavior in Williams Syndrome. Disclosure of Potential Conflicts. None 9/22/2016. Evaluation

Title 19/21 GMH/SA & Non-Title 19/21 SMI Behavioral Health Drug List Updated 4/01/2018

#55 PRESCRIBING AND MONITORING PSYCHI RIC MEDICATIONS

Prepared by: Elizabeth Vicens-Fernandez, LMHC, Ph.D.

Depression. There are several forms of depression (depressive disorders). Major depressive disorder and dysthymic disorder are the most common.

Title 19/21 GMH/SA & Non-Title 19/21 SMI Behavioral Health Drug List Updated 05/01/2015

Title 19/21 GMH/SA & Non-Title 19/21 SMI Behavioral Health Drug List Updated 01/01/2017

Transcription:

DEPARTMENT OF PSYCHIATRY Tuesday, Division of March Child and 14, Adolescent 2017 Psychiatry 8491 NW 39 th Ave. Gainesville, FL 32606 Phone: 352-265-4357 Fax: 352-627-4163 Welcome and thank you for choosing University of Florida Physicians! Dear Parent/Guardian, the information you provide here will help your provider in identifying your child s needs and how to best serve your family. Please be prepared to arrive 30 minutes early to complete clinic paperwork upon arrival. If you cannot keep this appointment, please call to cancel as soon as possible. If you fail to do so, you may not be allowed to reschedule your appointment. Please complete the attached assessment forms prior to your appointment. Please bring your completed paperwork, updated insurance information and any current medications in their original bottle to your appointment. The Child and Adolescent Psychiatry Clinic is located at 8491 NW 39th Ave. If you have any questions or need to reschedule, please call (352) 265-4357 Thank you for choosing UF Health for your healthcare needs and we look forward to serving you! PARENT OR GUARDIAN: PLEASE COMPLETE AND BRING THIS FORM TO CLINIC 1

Who referred you to our clinic? DEMOGRAPHICS: Name of the person completing this form: Relationship to the child: Child s Full Legal Name: Is there another name the child prefers being called? Child s Date of Birth: / / Age: Gender: Race: Religion: Is the child adopted? No Yes If yes, are they aware? No Yes Who lives in the same household as the child? Name Sex Age Relationship to Child Parent(s) occupation: 2

What are the main concerns that you have about your child? How long have you had these concerns? What are your goals for treatment of your child? Please circle all of the following symptoms that apply to your child: Sad or depressed mood Withdrawn from family or friends Loss of interest in activities or hobbies Feelings of guilt or worthlessness Feeling hopeless about the future Sleep disturbance Change in appetite Low energy or fatigue Trouble focusing or concentrating Thoughts of hurting self Thoughts of suicide Thoughts of hurting or killing others Drastic mood swings Episodes of decreased need for sleep Extreme hyperactivity Racing thoughts Talking so fast it s hard to understand Overly happy or euphoric Overly confident Hearing voices that other people cannot hear Seeing things other people cannot see Feeling paranoid Odd thinking or beliefs Irritability Severe angry outbursts (verbal or physical) Worrying too much Feeling or acting restless Muscle tension Panic or anxiety attacks Fear of looking stupid or being embarrassed Fear of offending others Any other fears or phobias Thoughts, feelings or pictures that come into the child s mind even if he/she does not want them to? Habits the child feels they must do even if he/she knows it does not make sense (for example excessive cleaning, checking, repeating, counting, organizing or hoarding things)? Poor body image Trying to lose weight even though he/she is not overweight Intentionally throwing up after eating 3

Easily loses temper Easily annoyed Defiant Argues with authority figures Annoying others on purpose Blaming others for his/her mistakes Resentful, spiteful or vindictive Lying Stealing Destroying property Setting fires Skipping school Hurting other people or animals Difficulty learning Trouble understanding social cues Difficulty forming or keeping friendships Being very sensitive to sound, light, touch or smell Tics, twitches or involuntary movements Making involuntary sounds Traumatic experiences: Has your child ever been exposed to actual or threatened death, serious injury, or sexual violence? No Yes If yes, does he/she have any of the following symptoms related to the traumatic event? Upsetting or intrusive memories Nightmares Flashbacks (feeling or acting like the event is happening again) Avoiding talking or thinking about what happened Feeling upset by reminders of the event Having out of body experiences Feeling like the world/surroundings are not real Angry outbursts Recklessness or self-destructive behavior Getting startled very easily Always looking around for signs of danger Trouble remembering some or all of what happened PAST PSYCHIATRIC HISTORY: Has your child ever seen a psychiatrist or therapist/counselor before? Name of provider Dates seen Reason 4

Has your child ever been admitted to a psychiatric hospital? Name of the hospital Dates Reason Has your child ever attempted suicide? No Yes If yes, please describe: Does your child engage in any self-harm behaviors (like cutting)? No Yes describe: If yes, please Has your child ever been violent or aggressive? No Yes If yes, please describe: FAMILY HISTORY: Please list any known psychiatric illnesses in blood relatives of the child: Psychiatric illness: Child s Mother Child s Father Child s siblings Depression Anxiety Bipolar disorder Psychosis Schizophrenia ADHD Intellectual disability or learning problems Autism Eating disorder Alcohol problems Drug problems Suicide Mother s side of the family Father s side of the family Does the child have any blood relatives with heart defects or arrhythmias? No Yes Unknown Does the child have any blood relatives who died suddenly at a young age? No Yes Unknown SUBSTANCE USE HISTORY: Does the child use: Alcohol Tobacco Illegal drugs Specify: 5

MEDICAL HISTORY: Does your child have any history of the following medical conditions (circle all that apply)? Allergies (describe) Loss of Consciousness Asthma Heart problems Respiratory Illness High Blood Pressure Diabetes Low Blood Pressure Convulsions/Seizures/Epilepsy Urogenital Problems Head Injury Vision Problems Dizziness or Fainting Hearing problems Any other serious illness or disease? Has your child ever had surgery? No Yes If yes, describe and give dates: Has your child ever had any serious injuries? No Yes If yes, describe and give dates: Biological females only: Has your child started menstruation? No Yes If yes, at what age Are periods regular? No Yes Date of last menstrual cycle / / Is there any change in symptom severity with periods? No Yes If yes, please describe MEDICATIONS: Please list all medication your child is currently taking: Name of medication Dose of medication Who prescribes it? 6

Please circle any medications your child has taken in the past: Alprazolam (Xanax) Diazepam (Valium) Mirtazapine (Remeron) Amitriptyline (Elavil) Duloxetine (Cymbalta) Nortriptyline (Pamelor) Amphetamine (Adderall) Escitalopram (Lexparo) Olanzapine (Zyprexa) Aripiprazole (Abilify) Fluoxetine (Prozac) Oxcarbazepine (Trileptal) Asenapine (Saphris) Fluphenazine (Prolixin) Paliperidone (Invega) Atomoxetine (Strattera) Fluvoxamine (Luvox) Paroxetine (Paxil) Bupropion (Wellbutrin) Guanfacine (Intuniv) Quetiapine (Seroquel) Buspirone (BuSpar) Haloperidol (Haldol) Risperidone (Risperdal) Carbamazepine (Tegretol) Iloperidone (Fanapt) Sertraline (Zoloft) Citalopram (Celexa) Imipramine (Tofranil) Topiramate (Topamax) Clomipramine (Anafranil) Lamotrigine (Lamictal) Trazodone (Desyrel) Clonazepam (Klonopin) Levomilnacipran (Fetzima) Valproic Acid (Depakote) Clonidine (Kapvay) Lisdexamfetamine (Vyvanse) Venlafaxine (Effexor) Clozapine (Clozaril) Lithium Vilazodone (Viibryd) Desipramine (Norpramin) Lorazepam (Ativan) Vortioxetine (Brintellix) Desvenlafaxine (Pristiq) Loxapine (Loxitane) Ziprasidone (Geodon) Dexmethylphenidate Lurasidone (Latuda) Other: (Focalin) Amphetamine (Adderall) Methylphenidate (Aptensio, Concerta, Daytrana, Metadate, Methylin, Ritalin, Quillivant) ALLERGIES (circle): No Known Drug Allergies Other: Please list any allergies the child has: SOCIAL HISTORY: Name of child s current school: Current grade: Did the child repeat any grades? No Yes Does the child have a 504 plan or IEP? No Yes Is the child in ESE or special needs classes? No Yes Has the child ever been suspended or expelled? No Yes Does the child get bullied by peers? No Yes Has the child ever been the victim of abuse? No Yes Has the child been arrested? No Yes Are there any weapons or guns in your home? No Yes If so, does your child have access to them? No Yes 7

DEVELOPMENTAL HISTORY: (Not all parents remember the answers to these questions. You can write down what you do remember or look back if you kept a baby book.) What was the length of the pregnancy? Were any medications or substances used during pregnancy? No Yes If yes, what? Any other complications of pregnancy or delivery? No Yes How much did the baby weigh at birth? Did the baby start breathing right away? No Yes Were there any problems with the baby after he/she was born? No Yes When did the baby leave the hospital? When the baby came home, were there any problems? No Yes When did the baby really smile (not gas )? When was the baby able to sit by him/herself (without help)? When did the baby walk by him/herself (without holding on)? When did baby say his/her first word? When did the baby say short sentences (such as go bye bye )? Did the child have trouble learning to speak? Was he/she different from brother or sister or other children? Is the child toilet trained? No Yes If yes, how old when trained? How old was the child when he/she was able to: When did the child learn to ride a tricycle? When did the child learn to ride a bicycle without training wheels? When was the child able to get dressed by him/herself? When was the child able to tie shoelaces? What hand does the child prefer to use? Right Left No Preference At what age did you notice this? Did anything else significant occur during the child s development years? TESTING HISTORY: Did the child ever have IQ or achievement testing? No Yes Has the child been tested for hearing abnormalities? No Yes Has the child been tested for speech/ language abnormalities? No Yes Has the child ever received occupational or physical therapy? No Yes OTHER: Has the child experienced any of the difficulties below? Please circle all that apply: Death of a parent, Death of other loved ones/close friend, Separation from parent or family, Parent separation/divorce, Loss of Home, Family financial problems, Parent with substance abuse problem, Conflicts with parents, Removal of child from home, Victim of crime or violence, Unwanted pregnancy, School problems, Illness in self, Illness in family (specify), Other: 8

2024 © healthdocbox.com Privacy Policy | Terms of Service | Feedback