Psychiatric Nurse Practitioner Intake Form. General Information. 1. Name. 2. Date of Birth. 3. Age. 4. Gender. 5. Referred by

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Psychiatric Nurse Practitioner Intake Form General Information 1. Name 2. Date of Birth 3. Age 4. Gender 5. Referred by 6. Emergency Contact & Phone Number 7. Please State your Main Reason for Coming in Today in one or two sentences 8. When did the problem start? 9. Are you ALLERGIC to any medications 10. List any drug, medication or other substance to which you are allergic

Psychiatric Nurse Practitioner Intake Form MEDICAL HISTORY 11. Who is your Primary Care Physician (PCP)? Please also give PCP's phone number and fax number 12. Names, phone numbers and fax numbers of other specialists you see 13. Do you have any of the following issues or conditions? Diabetes Migraines Thyroid Problems Asthma/COPD Heart Disease Hypertension Heart Murmur Stroke Irregular Heart Beat Seizures Disorder Concussions Blood Disorder Acid Reflux 14. Surgeries (if yes, please list)

15. Current Medications Psychiatric Nurse Practitioner Intake Form SOCIAL HISTORY 16. With whom do you live? 17. Marital Staus Single Married Divorced Other (please specify) 18. Children

19. Are you a student? If YES, list name of school and grade level 20. If no, did you graduate from High School? GED 21. College Attended? If YES, Degree earned 22. Average grades 23. Do you have any learning disabilities? 24. Did you repeat any grade level? 25. Did you have any discipline issues when you were in school?

26. Did or do you have a 504 plan, IEP or GIEP? 27. Are you currently working?, full time, part time 28. Occupation & Current Employer 29. Are you on disability? If YES, reason for the disability 30. Are you involved in any activities such as church, temple, sports, clubs? If yes, please list 31. Any past or current legal problems (i.e. DUIs, etc)? If, please explain 32. Do you have access to firearms?

33. If yes, are the firearms secured? Psychiatric Nurse Practitioner Intake Form Developmental Milestones (for kids 15 & under) 34. Any delay with walking, talking, potty training Don't Know 35. Any complications with pregnancy or delivery? Don't Know If YES, please explain Psychiatric Nurse Practitioner Intake Form PSYCHIATRIC HISTORY 36. Inpatient treatments (where and for what reason)

37. Outpatient Treatments 1 2 3 4 38. Current Therapist Name, Phone & Fax number, length of treatment 39. Physicians seen for psychiatric issues 1 2 3 40. Any history of suicide attempt? 41. Any past psychiatric diagnoses? 42. PLEASE LIST ANY OTHER PSYCH MEDS YOU HAVE TRIED IN THE PAST. PLEASE LIST THE NAME OF MED, DOSE OF MED AND DATES OF USE. PLEASE GIVE REASON FOR STOPPING: 1 2 3 4 Psychiatric Nurse Practitioner Intake Form SUBSTANCE ABUSE HISTORY

43. Do you drink Coffee? If YES, how many cups per day? 44. Do you drink Energy Drinks? If YES, how many per day? 45. Tobacco Use If YES, please quantify 46. Alcohol Use If yes, how much per week 47. Current or past illegal drug use

48. If YES, please identify type Cocaine Marijuana Heroin Other (please specify) 49. History of treatment for alcohol or drug use 50. If YES, please select all treatments you have had Rehab Outpatient Detox AA/NA Psychiatric Nurse Practitioner Intake Form CURRENT SYMPTOMS

51. Please check any CURRENT DEPRESSIVE SYMPTOMS Depressed or sad mood Feeling hopeless/helpless Anger/irritability Suicidal thoughts Loss of interest Feeling worthless Fatigue/loss of motivation Homicidal thoughts Poor focus Social isolation Decreased appetite Self-injurious behavior Negative thoughts Low self-esteem Crying Increased appetitie Sleep difficulties Total hours of sleep per day 52. Please check any CURRENT MOOD SYMPTOMS Elevated mood (people close to you notice a change from your normal self) Elevated self-esteem/over-confidence Poor decision making Racing thoughts Decreased need for sleep and still feel rested Feeling impulsive Spending excessive amounts of money Pressured or rapid speech Higher interest in sex than normal

53. Indicate CURRENT EATING DISORDER SYMPTOMS Intentionally trying to lose weight by restricting food intake Use of diet pills Over-exercising Vomiting to lose weight Laxative use to lose weight Binge eating Preoccupation with body image 54. Indicate CURRENT ANXIETY SYMPTOMS Excessive worrying Worries that keep you awake Bothered by crowds Feeling very tense due to worries Fear of leaving home Trouble making decisions Obsessive thoughts Very anxious when meeting new people "Need to get of the place" feeling Frequently worry about being judged by others Avoid going places Flashbacks/nightmares Daily rituals that are time consuming Avoid talking on the phone due to fears shortness of breath Nausea or knots in the stomach Dizziness Hands shaking Racing heart/palpitations Chest feels funny or pressure Sweats/chills

55. Indicate CURRENT ATTENTION/BEHAVIORAL SYMPTOMS Difficulty paying attention Easily distracted Problems with organization Trouble Listening Difficulty following instructions Difficulty giving attention to detail Forgetful in daily activities Make careless mistakes Lose things frequently Fidgety Often interrupt others Reckless driving Difficulty waiting your turn Unable to remain seated Defiance Losing temper easily Blame others Deliberately annoy others 56. Indicate all CURRENT PHYSICAL SYMPTOMS YOU ARE EXPEREINCING Headaches Back pain diarrhea neck pain Constipation Heavy or irregular periods Stomach pain Sexual dysfunction

57. Have you ever served in any branch of the military? 58. Any combat exposure? 59. Any history of abuse or interpersonal violence? 60. Please indicate CURRENT TRAUMA SYMPTOMS Recurent nightmares Flashbacks Feeling on edge frequently Sleep disruption related to the trauma Avoidance of talking about trauma Emotional/Physical symptoms when reminded of trauma Avoidance of people/places that remind you of the trauma Feeling detached or estranged from others Easily startled or jumpy Unable to remember certain aspects of the trauma Psychiatric Nurse Practitioner Intake Form FAMILY HISTORY 61. Please list anyone in your family bloodline who has been diagnosed with a psychiatric illness. Please identify relation to you and their diagnosis or symptoms

62. Has anyone in your family ever died of a sudden cardiac event under the age of 35?

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