Thank you for taking the time to complete this questionnaire. The information provided here will allow us to make the best use of your visit time. If there are physical conditions that prevent you from completing the form, we understand. If this is the case, we can review the information together in the visit. Please enter you name: Date Of Birth: Who is filling out the form: Patient Relationship: DO YOU HAVE A HISTORY OF ANY OF THE FOLLOWING MEDICAL CONDITIONS Asthma Hypertention Cardiac murmur Heart failure Diabetes Chronic Constipation Traumatic brain injury COPD / Emphysema Hyperlipidemia History of stroke or TIA Hypotension Cancer Fibromyalgia Migranes Sleep apnea Cardiac arrhythmia History of heart attack Thyroid disorder Anemia Neuropathy Seizures What is the main concern that you want to address at your psychiatry visit? Loss of interest in activities Decreased energy Worrying excessively over multiple things Reexperiencing traumatic events Problems staying asleep Repetitive or compulsive behaviors: Going for days without sleep and without feeling tired Acting impulsively (spending, gambling, etc) Repetitive or compulsive behaviors Forgetting how to perform known tasks Seeing things that others do not see Fatigue Poor self-esteem Anxious thoughts about specific concerns Nightmares / night terrors Avoidance of social gatherings Difficulty concentrating enough to read /watch tv Racing thoughts Hyperactive / unable to rest Concern about memory loss Problems finding words Feeling people are trying to watch or harm you Feeling hopeless/worthless Panic attacks Increase / decreased appetite Problems falling asleep Preoccupation with weight Periods of euphoria or highly elevated mood Periods of speaking fast / pressured Grunts, tics, or jerks Getting lost easily Hearing voices that are not real Other Past Mental Health CareHave you been ever diagnosed with a mental health condition by a medical provider? Yes No (e.g. Depression, bipolar, schizophrenia, ADHD)? If so, please list.(e.g. Depression, bipolar, schizophrenia, ADHD)? If so, please list. Have you ever been seen by a psychiatrist or therapist/counselor?Have you ever been seen by a psychiatrist or therapist/counselor? Yes No Have you ever been hospitalized for psychiatric care?Have you ever been hospitalized for psychiatric care? Yes No Please list and describe.Please list and describe. Have you ever been treated with any of the following medications? Mark all that apply and list any good or bad effects of the medications Loss of interest in activities Decreased energy Abilify Ambien Adderall Anafranil Antabuse Ascendin Ativan Buspar Campral Celexa Chloral Hydrate Clonidine Clozaril Cogentin Concerta Cymbalta Dalmane Depakote Dexedrine Doral Effexor Elavil Fanapt Geodon Halcion Haldol Clonazepam Invega Lamictal Latuda Lexapro Lithium Luesta Luvox Marplan Mellaril Methadone Miltown Nardil Norpramine Orap Pamelor Parnate Paxil Prosom Pristiq Prolixin Remeron Restoril Risperdal Ritalin Saphris Serax Seroquel Serzone Soma Sonata Strattera Suboxone Symmetrel Tegretol Thorazine Tofranil Topomax Traxene Trazodone Trileptal Valium Vibryd Vistraril Vivitrol Wellbutrin Xanax Zoloft Zyprexa Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Bad Substance Use HistoryHow often have you used the following substances?TabaccoMost recent use? # Of times per week, month, or year? How much do you use in a sitting? AlcoholMost recent use? # Of times per week, month, or year? How much do you use in a sitting? MarijuanaMost recent use? # Of times per week, month, or year? How much do you use in a sitting? CocaineMost recent use? # Of times per week, month, or year How much do you use in a sitting? Opiates (non-prescribed)Most recent use? # Of times per week, month, or year How much do you use in a sitting? Sedatives (Xanax, Ativan, Klonopin)Most recent use? # Of times per week, month, or year How much do you use in a sitting? PCP or LSDMost recent use? # Of times per week, month, or year How much do you use in a sitting? Mushrooms / PsilocybinMost recent use? # Of times per week, month, or year How much do you use in a sitting? OtherMost recent use? # Of times per week, month, or year How much do you use in a sitting? Family HistoryAlcohol use disorder: Anxiety disorders: Bipolar disorder: Depression: Substance / alcohol use disorder: Schizophrenia Suicide Social HistoryWhere do you live (house, apartment, skilled living facility? Who lives with you? How far did you go in school/highest level of education? What is/was your job/occupation? Are you married? Yes No If so, for how long? Do you have any religious beliefs that are important for us to know? Yes No Do you have a Living Will? Yes No Do you have a DNR/POLST? Yes No SafetyDo currently have thoughts of harming yourself? Yes No If so, please explain: Have you tried to hurt yourself in the past? Yes No If so, please explain: Do you currently have thoughts of hurting anyone else? Yes No If so, please explain: Have you tried to hurt anyone in the past? If so, please explain: Other InfromationIs there anything else that you would like me to know before our visit?Consent(Required) I agree to the privacy policy.CAPTCHA
