Happy Daisy Ltd. New Client intake Form Name Date Preferred name Pronouns Referred by Date of birth Age Race What are the issues for which you are seeking care? 1. 2. 3. Please check of any of the symptoms you have been recently experiencing: Depressed mood Loss of interest in activities Excessive guilt Feelings of worthlessness Hopelessness Recurrent thoughts of death Thinking about Suicide Suicide attempt Moving slower than usual Moving faster than usual Decreased concentration Increased appetite Decreased appetite Weight loss without dieting Sleeping too much Difficulty falling asleep Difficulty staying asleep Fatigue Increased irritability Feeling nervous or on edge Muscle tension Panic attacks Excessive energy Decreased need for sleep Sexual indiscretion Excessive spending Increased risky behavior Impulsivity Rituals Delusions Binging on food Inducing vomiting Restricting calories Thoughts of hurting or killing others Hallucinations Paranoia Cutting or self-harm behavior Flashbacks Nightmares Chronic feelings of emptiness Fear of abandonment Unstable friendships Difficulty controlling anger Fear of social situations Fear of embarrassment
Do you have a special diet of any kind? If so, please describe: How many caffeinated beverages do you drink in a day? (coffee, tea, Soda) Do you currently smoke cigarettes? How many per day? Do you use other tobacco products? (please specify) How many days per week do you drink any alcohol? How many drinks do you typically have? What is the most number of drinks you will drink in one day? In the past 3 months, what is the largest amount of drinks you have consumed in one day? Do you use marijuana or other recreational drugs? If so, which ones? Have you ever been treated for alcohol or drug use or abuse? Have you ever abused prescription medication? lf yes, which one(s)? Allergies Current prescription and over-the-counter medications, vitamins/minerals, or supplements: Name Dose Frequency Estimated Start Date Current medical problems:
Have you ever had any of the following conditions? Anemia Asthma Cancer Cardiac structural problems Chronic pain Dementia Diabetes Eating Disorder Gastrointestinal problems Low blood pressure Lung disease Neurological problems Seizure Sleep apnea Glaucoma Hormone problems Head injury Heart murmur High blood pressure High cholesterol HIV positive or AIDS Kidney problems Liver problems Snoring Stroke Suicide attempt Thyroid disease Urological problems When was your last physical? Were there any problems? If yes, please describe: Are you sexually active? ls there any chance that you might be pregnant? Are you planning to become pregnant? Form of contraception used? Hospitalizations: Location Dates Reason
Previous psychiatric Symptoms and treatments including therapy: (ADHD, anxiety, alcoholism, bipolar disorder, depression, drug abuse, eating disorder, OCD, PTSD, etc.) Diagnosis When symptoms began Treatment Previous psychiatric medications: ANTDEPRESSANTS Prozac (fluoxetine) Zoloft (sertraline) Luvox (fluvoxamine) Paxil (paroxetine) Celexa (citalopram) Lexapro (escitalopram) Effexor (venlafaxine) Cymbalta (duloxetine) Pristiq (desvenlafaxine) Fetzima (levomilna cipran) Viibryd (villazodone) Brintellix/Trintellix (vortioxetine) Wellbutrin (bupropion) Remeron (mirtazapine) Serzone (nefazodone) Anafranil (clomipramine) Pamelor (nortriptyline) Tofranil (imipramine) Elavil (amitriptyline) Asendin (amoхарine) Ludiomil (maprotiline) Norpramin (desipramine) Surmontil (trimipramine) Rozerem (ramelteon) Xanax (alprazolam) Ativan (lorazepam) Klonopin (clonazepam) Valium (diazepam) Buspar (buspirone) ADHD MEDICATIONS Adderall (amphetamine) Concerta (methylphenidate) Ritalin (methylphenidate) Strattera (atomoxetine) Focalin (dexmethylphenidate) ANTICONVULSANTS/MOOD STABILIZERS Lithium Lamictal (lamotrigine) Tegretol (carbamazepine) Trileptal (oxcarbazepine) Neurontin (gabapentin) Lyrica (pregabalin) Depakote (valproic acid) ANTPSYCHOTICS Seroquel (quetiapine) Zyprexa (olanzapine) Risperdal (risperidone)
Vivactil (protriptyline) EMSAM SLEEP MEDICATIONS/ANXIETY Trazodone Doxepin Ambien (zolpidem) Ambien (zolpidem) Restoril (temazepam) Geodon (ziprasidone) Abilify (aripiprazole) Rexulti (brexpiprazole) Latuda (lurasadone) Haldol (haloperidol) Other Current medical and psychiatric providers: Primary care provider: Therapist: Other: Family psychiatric history Please note any psychiatric conditions you believe your family members have: Mother Father Sibling Sibling Sibling Were you adopted? Have any of your relatives been diagnosed with diagnosed with bipolar disorder? ADHD? Schizophrenia? Has anyone in your family been treated with a psychiatric medication? Which ones? Were they effective? Developmental history: When your mother was pregnant with you, were there any problems during the pregnancy or birth? As far as you know, did you meet your developmental milestones? (e.g. walking and talking when expected)
Social: Where did you grow up? Did your parents divorce? If so, how old were you? Describe your relationship with your mother: Describe your relationship with your father: Overall, how would you describe your childhood? Do you have a history of being abused emotionally, sexually, physically, or by neglect? If so, please describe what, at what age, and by whom: Have you had a trauma in your life that you believe is causing you to have Symptoms now (accident, assault, natural disaster, etc.? If yes, please describe including the age this occurred: Were you in a special education program? Did you graduate from high school? Did you attend college? Where? Major? What is your current occupation? Where do you work or go to school? Do you Currently have any legal problems? If so, please describe: Do you like your job? How would you describe your Sexual orientation? Are you currently in a relationship? Describe your relationship with your significant other: Do you have any children? If so, list ages and gender: List everyone who currently lives with you: To whom do you turn when you need support? Do you belong to a religious or spiritual group? lf yes, what is your current level of involvement?
What do you do for fun? Do you regularly exercise? How often? What type of exercise? Do you regularly meditate? Do you do yoga? Do you engage in any other wellness activities (please describe)? What are your goals for treatment? ls there anything else you would like me to know?