Patient History Form

Similar documents
PSYCHIATRY INTAKE FORM

Appendix: Psychotropic Medication Reference Tables

New Patient Questionnaire

Medications and Children Disorders

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

Joseph S. Weiner, MD, PC Patient History Form

Mental Health Intake Form

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

Mental Health Intake Form

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

Adult Initial Assessment / Patient Questionnaire Page 1

GoPrivateMD General Information & History

Guide to Psychiatric Medications for Children and Adolescents

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

TRANSCRANIAL MAGNETIC STIMULATION & BRAIN MUSIC THERAPY

RHEUMATOLOGY PATIENT HISTORY FORM

MO Medicaid Foster Care Drugs FY10-FY14

Dealing with a Mental Health Crisis

Schedule FDA & literature based indications

USF Health Psychiatry Clinic. New Patient Questionnaire Adult

SAMIR PATEL, MD. Patient Medical History

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

Germantown Private Psychiatry PLLC

Welcome and thank you for choosing University of Florida Physicians!

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

NEW PATIENT INTAKE FORM

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

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

Steps for Initiating Electroconvulsive Therapy Treatment

Psychiatric Medications. Positive and negative effects in the classroom

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

HCA BHS Prescribing Guidelines Committee - Approved Medications 2012

Psychiatric Evaluation Intake Form

Psychiatric Evaluation Intake Form

ELEMENTAL CENTER MENTAL HEALTH INTAKE FORM

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

CENPATICO INTEGRATED CARE BEHAVIORAL HEALTH DRUG LIST BY DRUG CLASS

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

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

Supplement: Tables and Figures

Briefly state the reason for this evaluation: Patient s Name: Sex: Male/Female (circle one) Date of Birth: Age: Patient s Social Security #

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

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

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

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

Study Guidelines for Quiz #1

CARD TOBACCO: Cigarettes, E- Cigarettes, Cigars, Tobacco Pipe, Chewing Tobacco, Snuff

Physician initials. Date: / / Birthdate: / / Age: Sex: F M

NorthSTAR. Pharmacy Manual

Child & Adolescent Patient History Questionnaire

#55 PRESCRIBING AND MONITORING PSYCHI RIC MEDICATIONS

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

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

Psychiatric Intake Form (Please note: if you are not comfortable answering any of the following questions, feel free to leave the space blank)

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

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

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

Use Brand Only. Preferred Drug Status PRIOR AUTHORIZATION REQUIRED

Adult Intake Form. Page 1 of 5

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

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

Branko Radisavljevic, M.D.

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

Creating Partnerships. Laine Young-Walker, MD

Medically Accepted Indications for Pediatric Use of Psychotropic Medications by

Psychiatric Distress in Chronic & Terminal Illness Barb Henry, ARNP, MSN

AHCCCS BEHAVIORAL HEALTH DRUG LIST EFFECTIVE OCTOBER 1, 2016

Patients considering TMS Therapy

5151 Research Dr NW Huntsville, AL Ph Fax

PACIFIC PSYCHIATRY, INC.

New Patient Information - Adolescent

Psychiatric Evaluation Intake Form

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

Medical condition SELF Mother Father Sibling (list brother or sister) Anxiety Bipolar disorder Heart Disease Depression Diabetes High Cholesterol

ALAMEDA COUNTY BEHAVIORAL HEALTH CARE SERVICES MEDICATION FORMULARY

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

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

Patients considering TMS Therapy

LEXAPRO PRESENT TENSE SPANISH VERB CONJUGATIONS SPANISH VERBS

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

LifePath Systems Medication and Laboratory Formulary

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

Short Clinical Guidelines: General Anxiety Disorder (GAD)

Pharmacotherapy of Anxiety Disorders (GAD, Panic, & SAD) Declaration of Interests

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

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

1911 Keller Andrews Road Sanford, NC

Depression. University of Illinois at Chicago College of Nursing

WELLBUTRIN COMBINATIONS MONITORING PAXIL BLOOD PRESSURE BAD

COMMONLY PRESCRIBED PSYCHOTROPIC MEDICATIONS NAME Generic (Trade) DOSAGE KEY CLINICAL INFORMATION Antidepressant Medications*

Patient Registration Form. Patient Name: Social Security #: Billing Address: City: State: Zip Code: Home Address. Home Phone#: Cell #: Work #:

Diagnostic Screening Tool

Diagnostic Screening Tool

OBJECTIVES PSYCHOTROPIC MEDICATIONS WHAT IS PSYCHOTROPIC MEDICATION?

Where is your pain located? Please use the diagram below to indicate where most of your pain is located.

37 South 2 nd East, Rexburg, ID

Transcription:

Patient History Form Date: / / NAME: Last First Middle Birthdate: / / Age: Sex: F M Please read the following questions and answer to the best of your ability by placing a check mark in the appropriate boxes or fill in the blank as directed. YOUR COOPERATION IS APPRECIATED. How did you hear about this clinic? OR Referred by: PLEASE STATE IN YOUR OWN WORDS WHY YOU HAVE COME TO ALABAMA PSYCHIATRY AND COUNSELING: PSYCHIATRIC HOSPITALIZATIONS (include where, when, & for what reason): Yes No Have you ever had ECT? Yes No Have you had counseling? Yes No 1

SYSTEMS REVIEW (PSYCHIATRIC) PLEASE CHECK: In the past month, have you had any of the following problems? Felt sad or low? Sensitivity or Frequent crying? Felt upset or annoyed at little things? Had trouble enjoying things that used to be fun? Worried that you might hurt yourself or felt like you wanted to die? Had felt bad about yourself or that you are a failure or have let yourself or your family down? Felt Hopeless or Worthless? Had trouble falling or staying asleep? Had felt more self confident? Had felt more energetic and more active then usual? Had racing thoughts (thoughts jump from topic to topic)? Had taken more risks in your daily life? Work? or Other Activities? Felt driven to perform certain acts over and over, such as excessive checking, counting or arranging objects? Felt more nervous and anxious than usual? Worrying too much about different things? Exposed to a significant traumatic event? Had recurrent distressing dreams / nightmares? Felt jumpy or easily startled by noises? Felt emotionally distant from others? Bothered by thoughts or images that repeatedly enter your mind such as concerns with contamination or keeping objects in perfect order? Hear voices or sounds that others do not hear? See things that others do not see? Sleeping too much? Unable to stop worrying? Smell things others don t smell? Had no appetite or been eating too much? Felt more tired than usual or have less energy? Trouble thinking, concentrating or making decisions? Moving or speaking so slowly that other people have noticed? Felt fidgety or restless that you have been moving around a lot more than usual? Felt like you have no one to talk to? Sexual problems? Gender concerns? Difficulties with sexual arousal? Had trouble relaxing? Felt like you are falling apart and going to pieces? Anxiety in social situation? Social phobia? I don t like my body? Intense fear of gaining weight? Excessive fasting to loose weight? Binge eating? Self-induced vomiting? Laxative abuse? Paranoid or suspicious? Felt paranoid or suspicious such as being plotted against, followed or monitored? Memory problems / Forgetfullness? Use of drugs? Abuse of Alcohol? Smoke cigarettes? 2

SYSTEMS REVIEW (MEDICAL) In the past month, have you had any of the following problems? GENERAL NERVOUS SYSTEM HEART AND LUNGS Recent weight gain; how much Headaches Chest Pain Recent weight loss: how much Dizziness Palpitations Fatigue Fainting or loss of consciousness Shortness of breath Weakness Numbness or tingling Fainting Fever Memory loss Swollen legs and feet Night sweats Seizure MUSCLE/JOINTS/BONES STOMACH AND INTESTINES KIDNEY / BLADDER Numbness Nausea Frequent urination Joint pain Heartburn Burning on urination Muscle weakness Stomach pain Blood in urine Joint swelling Vomiting Where? Yellow jaundice WOMEN ONLY Increasing constipation Abnormal papsmear EARS Persistent diarrhea Irregular periods Ringing in ears Blood in stools Bleeding between periods Loss of hearing Black stools PMS EYES SKIN OTHER PROBLEMS Pain Redness Redness Rash Loss of vision Nodules/bumps Double or blurred vision Hair loss Dryness Color changes of hands or feet THROAT BLOOD Frequent sore throats Anemia Hoarseness Clots Difficulty in swallowing Excessive Bleeding Pain in jaw 3

PAST MEDICAL HISTORY Do you now or have you ever had: Diabetes Heart murmur Crohn s disease High blood pressure Pneumonia Colitis High cholesterol Pulmonary embolism Anemia Hypothyroidism Asthma Jaundice Goiter Emphysema Hepatitis Cancer (type) Stroke Stomach or peptic ulcer Leukemia Epilepsy (seizures) Rheumatic fever Psoriasis Cataracts Tuberculosis Angina Kidney disease HIV/AIDS Heart problems Kidney stones Other medical conditions (please list): Do you now or have you ever had: PERSONAL HISTORY Where were your born & raised? What is your highest education? High school Some college College graduate Advanced degree Marital status: Never married Married Divorced Separated Widowed Partnered/significant other What is your current or past occupation? Are you currently working? : Yes No Hours/week If not, are you retired disabled sick leave? Do you receive disability or SSI? Yes No If yes, for what disability & how long? Have you ever had legal problems? (specify) 4

CURRENT MEDICATIONS Please list any medications that you are now taking. Include non-prescription medications & vitamins or supplements: Name of drug Dose (strength & number of pills per day) How long have you been taking this? Drug allergies: No Yes To what? DRUG ALLEGIES 5

PAST MEDICATIONS Have you ever been on any of the following medications? ANTIDEPRESSANTS ANXIETY MEDICATIONS ADHD MEDICATIONS Amitriptyline (Elavil) Alprazolam (Xanax) Adderall Notriptyline Clonazepam (Klonopin) Vyvanse Imipramine Lorazepam (Ativan) Dexedrine Clomipramine (Anafranil) Diazepam (Valium) Methylphenidate (Ritalin) Desipramine Chlordiazepoxide (Librium) Concerta Doxepin Oxazepam (Serax) Focalin Amoxapine Hydroxyzine (Vistaril) Adzenys XR (Amphetamine) Fluoxetine (Prozac) Buspirone (Buspar) Metadate (Methylphenidate) Citalopram (Celexa) Pregabalin (Lyrica) Bupropion (Wellbutrin) Escitalopram (Lexapro) Atomoxetine (Strattera) Paroxetine (Paxil) ANTIPSYCHOTICS Clonidine (Catapress) Sertraline (Zoloft) Risperidone (Risperdal) Guanfacine (Tenex; Intuniv) Fluvoxamine (Luvox) Quetiapine (Seroquel) Venlafaxine (Effexor) Olanzapine (Zyprexa) SLEEP MEDICATIONS Desvenlafaxine (Pristiq) Ziprasidone (Geodon) Trazodone Duloxetine (Cymbalta) Clozapine (Clozaril) Zolpidem (Ambien) Vortioxetine (Brintellix) Aripiprazole (Abilify) Zaleplon (Sonata) Vilazodone (Viibryd) Paliperidone (Invega) Eszopiclone (Lunesta) Bupropion (Wellbutrin) Asenapine (Saphris) Ramelteon Mirtazapine (Remeron) Iloperidone (Fanapt) Triazolam (Halcion) Phenelzineu (Nardil) Caripraszine (Vraylar) Temazepam (Restoril) Brexpiprazole (Rexulti) MOOD STABALIZERS Haloperidol (Haldol) SUBSTANCE USE TREATMENT Valproic Acid (Depakote) Fluphenazine (Prolixin) Methadone Lamotrigine (Lamictal) Pimozide (Orap) Buprenorphine (Subutex) Carbamazepine (Tegretol) Chlorpromazine (Thorazine) Disulfiram (Antabuse Oxcarbazepine (Trileptal) Perphenazine (Trilafon) Naltrexone (Vivitrol) Topiramate (Topamax Thioridazine Bupropion (Zyban) Gabapentin (Neurontin) Thiothixene (Navane) Varenicline (Chantix) Lithium Trifluoperazine (Stelazine) Acamprosate (Campra) 6

SUBSTANCE USE DRUG CATEGORY Do you currently use this? Comments ALCOHOL CANNABIS: Marijuana, hashish, hash oil STIMULANTS: Cocaine, crack STIMULANTS: Methamphetamine speed, ice, crank AMPHETAMINES/OTHER STIMULANTS: Ritalin, Benzedrine, Dexedrine BENZODIAZEPINES/TRANQUILIZERS: Valium, Librium, Halcion, Xanax, Diazepam, Roofies SEDATIVES/HYPNOTICS/BARBITURATES: Amytal, Seconal, Dalmane, Quaalude, Phenobarbital HEROIN STREET OR ILLICIT METHADONE OTHER OPIOIDS: Tylenol #2 & #3, 282 S, 292 S, Percodan, Percocet, Opium, Morphine, Demerol, Dilaudid HALLUCINOGENS: LSD, PCP, STP, MDA, DAT, mescaline, peyote, mushrooms, ecstasy (MDMA), nitrous oxide INHALANTS: Glue, gasoline, aerosols, paint thinner, poppers, rush, locker room OTHER: specify) 7

FAMILY HISTORY Please list all blood relatives who have been diagnosed with the following conditions: Depression / Major Depression /Suicide Anxiety Disorders Bipolar Disorders Schizophrenia / Schizoaffective Disorder / Psychotic Disorders Alcoholism Drug Abuse Heart disease, high blood pressure, arrhythmias Diabetes Seizure Stroke Thyroid Disorders Cancer OTHER 8

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