Evergreen Behavioral Health Psychiatric Intake Form. Name: Date: Date of Birth:!

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Name: Date: Date of Birth: NOTE: Please also fill out the standard Evergreen Behavioral Health Adult Client Information form to accompany this one if you have not yet done so. Please also bring in recent medical records if possible. What is the main reason you would like to see a psychiatrist? Do you have any additional goals? How were you referred? Name of therapist? Name of medical provider? Name of prior psychiatrist or psychiatric nurse practitioner? Psychiatric History: Have you been diagnosed with any psychiatric disorder(s) previously? If so, please specify: Have you ever been hospitalized for any psychiatric reason? Y N Reason: Date(s): Do you have a history of any of the following? Attempted suicide? Y N Date(s): Eating disorder? Y N Date(s): Nearly attempted suicide? Y N Date(s): Violence against others (e.g. threats, fights)? Y N Date(s): Self harm (e.g. cutting or burning yourself)? Y N Date(s): 1 of 5

Medical History: Do you have now, or have you ever had the following medical problems? What was the date of your last physical exam? Problem Now Past Details High blood pressure Heart disease or arrhythmia Asthma COPD or emphysema Cancer Diabetes Obesity Chronic pain Thyroid disorder Autoimmune disorder Vision problem Hearing problem Stomach, esophagus, or intestinal problem Liver disease Skin problem Sexual or reproductive problem Seizure disorder Stroke Dementia Movement disorder Head injury Other 2 of 5

Medical History, continued: Have you ever stayed in a hospital? Y N Date: Reason: Have you ever had surgery? Y N Date: Reason: Please list all allergies to medications, foods, or the environment: Please list all of your current medications, including over-the-counter medications, vitamins, and supplements: Name of medication Dose How often do you take it? When was it started? Prescriber Alcohol and Drug History: Has anyone ever thought that you might have a problem with alcohol? Y N Has anyone ever thought that you might have a problem with prescribed drugs? Y N Has anyone ever thought that you might have a problem with illegal drugs? Y N Are you interested in quitting tobacco or nicotine use? Y N N/A Have you ever received treatment for addiction? Y N 3 of 5

Alcohol and Drug History, Continued: How much do you use of the following substances? Family history: Type Route (e.g. oral) Amount (e.g. mg) per Day / Week/ Month Alcohol Tobacco or other nicotine Marijuana Caffeine Pain pills (opiates) Sleep pills (e.g. Ambien) Benzodiazepines ADHD meds Cocaine Methamphetamine Heroin Other Has any of your biological relatives had the following problems? (check all that apply) Problem Mother Father Sibling Child Grandparent Aunt/ Uncle Any of the medical problems listed above? Depression Anxiety Bipolar disorder Schizophrenia Suicide Alcohol or drug addiction Cousin 4 of 5

Problem Mother Father Sibling Child Grandparent Aunt/ Uncle Cousin Other psychiatric problem Social history: With whom do you live? What is your marital status? Have you been married previously? Y N How many children do you have? What are their ages? What is your highest level of education? Occupation? Currently employed? Y N Social History, continued: Do you have any current legal problems? Y N Details: Have you been charged with any crimes in the past? Y N What were they? Have you spent any time in jail or prison? Y N Details: Please list any current stressors (e.g. going through divorce, recent move, started new job)? 5 of 5

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