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Clinical History FormPatient First Name: _________________________Patient Last Name: _____________________Date Completed: ___________________________Patient Date of Birth: ___________________Primary Care Physician: ______________________ Physician Phone: _______________________Who referred you to this office: _______________________________________________________________Reason for visit:______________________________ How long has this been a problem__________________________Stressors: Given the list of categories below, how much stress is each area currently causing you?NoneMildModerateSevereFamily????Friends????Relationships????Educational????Economic????Occupational????Housing????Legal????Health????Review of Systems Please look at the list of physical symptoms below and check off any that you have experienced in the last several days. If you have NOT experienced any symptoms in an area, be sure to check “None of the above” for that area. 245554596520Eyes Eye painEye dischargeEye rednessBlurred or double visionVisual changeHistory of eye surgerySensitivity to lightScotomas (Blind spots)Retinal hemorrhage (Floaters in vision)Amaurosis (Feeling like a curtain is pulled over vision)Other:None of the above eye issues. 00Eyes Eye painEye dischargeEye rednessBlurred or double visionVisual changeHistory of eye surgerySensitivity to lightScotomas (Blind spots)Retinal hemorrhage (Floaters in vision)Amaurosis (Feeling like a curtain is pulled over vision)Other:None of the above eye issues. 10604588138Constitutional Chronic painLoss of appetiteIncrease in appetiteUnexplained weight lossWeight gainFatigue/LethargyUnexplained feverHot or Cold spellsNight sweatsSleeping pattern disruptionMalaise (Flu-like or Vague sick feeling)Other:None of the above constitutional issues. 00Constitutional Chronic painLoss of appetiteIncrease in appetiteUnexplained weight lossWeight gainFatigue/LethargyUnexplained feverHot or Cold spellsNight sweatsSleeping pattern disruptionMalaise (Flu-like or Vague sick feeling)Other:None of the above constitutional issues. 4760595101600Ears, Nose, Mouth, and ThroatEaracheTinnitus (Ringing in ears)Decreased hearing or hearing lossFrequent ear infectionsFrequent nose bleedsSinus congestionRunny nose/Post-nasal dripDifficulty swallowingFrequent sore throatProlonged hoarsenessPain in jaw or toothDry mouthOther:None of the above ear, nose, mouth, or throat issues. 00Ears, Nose, Mouth, and ThroatEaracheTinnitus (Ringing in ears)Decreased hearing or hearing lossFrequent ear infectionsFrequent nose bleedsSinus congestionRunny nose/Post-nasal dripDifficulty swallowingFrequent sore throatProlonged hoarsenessPain in jaw or toothDry mouthOther:None of the above ear, nose, mouth, or throat issues. 4720717461391Musculoskeletal Swelling in jointsRedness of jointsOther joint pains or stiffnessMuscle pain or crampingMuscle weaknessMuscle stiffnessDecreased range of motionBack pain or stiffnessHistory of fracturesPast injury to spine or jointsOther:None of the above musculoskeletal issues. 00Musculoskeletal Swelling in jointsRedness of jointsOther joint pains or stiffnessMuscle pain or crampingMuscle weaknessMuscle stiffnessDecreased range of motionBack pain or stiffnessHistory of fracturesPast injury to spine or jointsOther:None of the above musculoskeletal issues. 2457069456819Respiratory Pain with breathingChronic coughChronic shortness of breathChronic wheezing/AsthmaExcessive phlegmCoughing bloodNocturnal Dyspnea (Shortness of breath at night)Other:None of the above respiratory issues. 00Respiratory Pain with breathingChronic coughChronic shortness of breathChronic wheezing/AsthmaExcessive phlegmCoughing bloodNocturnal Dyspnea (Shortness of breath at night)Other:None of the above respiratory issues. 81407456184Cardiovascular Chest painPacemakerPalpitations (Fast or irregular heartbeat)Swollen feet or handsFainting spellsShortness of breath with exerciseOther:None of the above cardiovascular issues. 00Cardiovascular Chest painPacemakerPalpitations (Fast or irregular heartbeat)Swollen feet or handsFainting spellsShortness of breath with exerciseOther:None of the above cardiovascular issues. 47257973664077Change in appearance of stoolBlood in stoolDark/Tarry stoolLoss of bowel controlNone of the above gastrointestinal issues. 00Change in appearance of stoolBlood in stoolDark/Tarry stoolLoss of bowel controlNone of the above gastrointestinal issues. 24575773668522HeartburnDifficulty swallowing solids or liquidsRecent loss in appetiteSensitivity to milk productsJaundice (Yellow skin)00HeartburnDifficulty swallowing solids or liquidsRecent loss in appetiteSensitivity to milk productsJaundice (Yellow skin)47238925684520Hematologic/Lymphatic Blood clotsEasy bleeding after surgery or dental workHistory of blood transfusionExcessive bruising or bleedingSwollen glands (Neck, armpits, groin)Other:None of the above hematologic or lymphatic issues. 00Hematologic/Lymphatic Blood clotsEasy bleeding after surgery or dental workHistory of blood transfusionExcessive bruising or bleedingSwollen glands (Neck, armpits, groin)Other:None of the above hematologic or lymphatic issues. 24422105690870Endocrine Severe menopausal symptomsCold or heat intoleranceExcessive appetiteExcessive thirst or urinationExcessive sweatingOther:None of the above endocrine issues. 00Endocrine Severe menopausal symptomsCold or heat intoleranceExcessive appetiteExcessive thirst or urinationExcessive sweatingOther:None of the above endocrine issues. 850905719572Allergic/Immunologic Frequent infectionsHivesAnaphylaxis reactionOther:None of the above allergic or immunologic issues. 00Allergic/Immunologic Frequent infectionsHivesAnaphylaxis reactionOther:None of the above allergic or immunologic issues. 7924835941Gastrointestinal Excessive flatulence or belchingDiarrheaConstipationPersistent nausea/vomitingAbdominal painOther:00Gastrointestinal Excessive flatulence or belchingDiarrheaConstipationPersistent nausea/vomitingAbdominal painOther:803563660371Neurological ParalysisFainting spells or blackoutsDizziness/VertigoDrowsinessSlurred speechSpeech problems (Other)Short term memory troubleMemory difficulties (loss)Frequent headachesMuscle weaknessNumbess/Tingling sensationsNeuropathy (Numbness in feet)Tremor in hands/shakingMuscle spasms or tremorsOther:None of the above neurological issues00Neurological ParalysisFainting spells or blackoutsDizziness/VertigoDrowsinessSlurred speechSpeech problems (Other)Short term memory troubleMemory difficulties (loss)Frequent headachesMuscle weaknessNumbess/Tingling sensationsNeuropathy (Numbness in feet)Tremor in hands/shakingMuscle spasms or tremorsOther:None of the above neurological issues4720717461391Genitourinary (Men) Slow urine streamScrotal painLump or mass in the testiclesAbnormal penis dischargeTrouble getting/maintaining erectionsInability to ejaculate/orgasmAny other sexual or sex organ concernsOther:None of the above sex-specific genitourinary issues. 00Genitourinary (Men) Slow urine streamScrotal painLump or mass in the testiclesAbnormal penis dischargeTrouble getting/maintaining erectionsInability to ejaculate/orgasmAny other sexual or sex organ concernsOther:None of the above sex-specific genitourinary issues. 2457069456819Genitourinary (Women) Unusual vaginal dischargeVaginal pain, bleeding, soreness, or drynessGenital soresHeavy or irregular periodsNo menses (Periods stopped)Currently pregnantSterility/InfertilityAny other sexual or sex organ concernsOther:None of the above sex-specific genitourinary issues. 00Genitourinary (Women) Unusual vaginal dischargeVaginal pain, bleeding, soreness, or drynessGenital soresHeavy or irregular periodsNo menses (Periods stopped)Currently pregnantSterility/InfertilityAny other sexual or sex organ concernsOther:None of the above sex-specific genitourinary issues. 81407456184Genitourinary (General) Loss of urine controlPainful/Burning urinationBlood in urineIncreased frequency of urinationUp more than twice/night to urinateUrine retentionFrequent urine infectionsOther:None of the above general genitourinary issues. 00Genitourinary (General) Loss of urine controlPainful/Burning urinationBlood in urineIncreased frequency of urinationUp more than twice/night to urinateUrine retentionFrequent urine infectionsOther:None of the above general genitourinary issues. 47256703663950Psychiatric In-depth review of psychiatric system appears earlier in documentFeeling depressedDifficulty concentratingPhobias/Unexplained fearsNo pleasure from life anymoreAnxietyInsomniaExcessive moodinessStressDisturbing thoughtsManic episodesConfusionMemory lossOther:None of the above psychiatric issues00Psychiatric In-depth review of psychiatric system appears earlier in documentFeeling depressedDifficulty concentratingPhobias/Unexplained fearsNo pleasure from life anymoreAnxietyInsomniaExcessive moodinessStressDisturbing thoughtsManic episodesConfusionMemory lossOther:None of the above psychiatric issues24574503668395Integumentary (Skin/Breast and Hair) LesionsUnusual moleEasy bruisingIncreased perspirationRashesChronic dry skinItchy skin or scalpHair or nail changesHair lossBreast tendernessBreast dischargeBreast lump or massOther:None of the above integumentary issues00Integumentary (Skin/Breast and Hair) LesionsUnusual moleEasy bruisingIncreased perspirationRashesChronic dry skinItchy skin or scalpHair or nail changesHair lossBreast tendernessBreast dischargeBreast lump or massOther:None of the above integumentary issuesSubstance Abuse History: Do you have a history of recreational drug use/Alcohol abuse? ? Yes ? NoSubstance UsedYesNoAge of first useAge of last useHow was it taken:Amount usedDays per monthAmphetamines/SpeedO OralO NasalO InjectedO InhaledBarbituates/DownersO OralO NasalO InjectedO InhaledOpiatesO OralO NasalO InjectedO InhaledCocaineO OralO NasalO InjectedO InhaledPsychedelics (LSD, Ecstasy, Bath salts, etc)O OralO NasalO InjectedO InhaledInhalantsO OralO NasalO InjectedO InhaledCannabis/MarijuanaO OralO NasalO InjectedO InhaledAlcoholBenzodiazepinesO OralO NasalO InjectedO InhaledOther:O OralO NasalO InjectedO InhaledIf answered YES, fill out table below to the best of your knowledge:Substance Abuse Treatment History: Did you receive any treatment for substance abuse? ? Yes ? NoIf answered YES, fill out table below to the best of your knowledge:Treatment TypeYesNoNumber of times attendedAge of first treatmentAge of last treatment Additional information (i.e. graduated, discharged, etc.)InpatientIntensive OutpatientOutpatient12-Step Program Consequences of Substance Abuse: Have you experienced any of these consequences as a result of alcohol consumption or abuse of substances? (Please check all that apply) No consequencesFelt that you needed to cut down on drinkingBeen annoyed by others criticizing your drinkingFelt guilty about drinkingNeeding a drink first thing in the morningIncreased toleranceWithdrawal (shakes, sweating, nausea, rapid heart rate)SeizuresBlackoutsEffects on physical healthUsing/consuming more than intendedUnintentional overdoseDUIArrestsPhysical fights or assaultsRelationship conflictsProblems with moneyJob loss or problems at work/schoolOther:______________________________________________________________________Prior Inpatient Treatment/ hospitalizations (for psychiatric, emotional, or substance abuse disorder)?? Yes ? NoIf yes, please Describe:ReasonDate HospitalizedWherePrior Outpatient Psychiatric Treatment?? Yes ? NoIf yes, please describe:ReasonDates TreatedBy WhomPast Psychiatric History: Suicide/Self HarmHave you ever tried to harm or kill yourself? ??Yes ??NoIf yes, please answer the following questions. Was your intent to die? ??Yes ??NoHow many times has this occurred? _______________________What was the most severe episode and when? _____________________________________________________________________________________________________________________When was your most recent episode of suicidal thoughts or attempts? ______________________________________________________________________________________________________________________Have you had any history of violent behavior? ??Yes ??NoIf yes, please describe: ______________________________________________________________________________________________________________________Past Medical HistoryPlease check the following boxes for physical health problems you have had or currently experience.No problemsFibromyalgiaIron deficiencyAllergiesGall bladder diseaseKidney diseaseAnemiaGastritis/UlcerKidney stonesArthritisGlaucomaLiver diseaseAsthmaGoutLupusBack ProblemsHearing lossMigraine headachesCancerHeart diseaseMultiple sclerosisCataractsHeard defect from birthObesity or overweightChickenpoxHeart valve problemsParkinsons diseaseChronic bronchitisHemrrhoidsPolypsCOPD (Emphysema)HepatitisSeizuresDiabetesHerniaSleep apneaDiverticulitissHIVStroke/TIAFainting spellsHypertension (high blood pressure)Testosterone (low)High cholesterolHypotension (low blood pressure)Thyroid problemsOther: Inflammatory bowel diseaseTuberculosisPlease check the following boxes for past surgical history. No surgical historyHip/Knee/Ankle/FootPenisBack/NeckHysterectomy (ovaries removed)ProstateBrain/HeadHysterecomty (ovaries retained)Kidney stonesCardiacKidneyShoulder/Elbow/Wrist/HandEar/Nose/ThroatLiverTonsilsGall bladderLungVaginaHerniaPancreasWeight loss surgeryPelvisOTHER:Past Psychiatric Medications (If you have ever taken any of the following medications, indicate the date, dosage, and how helpful they were)AntidepressantsCheck if takenWhen?Dosage?Did it help?Any side effects?Prozac (fluoxetine)?Yes ? NoYes ? NoZoloft (sertraline)?Yes ? NoYes ? NoLuvox (fluvoxamine)?Yes ? NoYes ? NoPaxil (paroxetine)?Yes ? NoYes ? NoCelexa (citalopram)?Yes ? NoYes ? NoEffexor (venlafaxine)?Yes ? NoYes ? NoCymbalta (duloxetine)?Yes ? NoYes ? NoWellbutrin (bupropion)?Yes ? NoYes ? NoRemeron (mirtazapine)?Yes ? NoYes ? NoSerzone (nefazodone)?Yes ? NoYes ? NoAnafranil (clomipramine)?Yes ? NoYes ? NoPamelor (nortrptyline)?Yes ? NoYes ? NoTofranil (imipramine)?Yes ? NoYes ? NoElavil (amitriptyline)?Yes ? NoYes ? NoPristiq (desvenlafaxin)?Yes ? NoYes ? NoDesyrel (trazadone)?Yes ? NoYes ? NoViibryd (vilazodone)?Yes ? NoYes ? NoAdapin (doxepin)?Yes ? NoYes ? NoNorpramin (desipramine)?Yes ? NoYes ? NoLexapro (escitalopram)?Yes ? NoYes ? NoAntipsychotics/Mood StabilizersCheck if takenWhen?Dosage?Did it help?Any side effects?Seroquel (quetiapine)?Yes ? NoYes ? NoZyprexa (olanzapine)?Yes ? NoYes ? NoGeodon (ziprasidone)?Yes ? NoYes ? NoAbilify (aripiprazole)?Yes ? NoYes ? NoClozaril (clozapine)?Yes ? NoYes ? NoHaldol (haloperidol)?Yes ? NoYes ? NoInvega?Yes ? NoYes ? NoLatuda?Yes ? NoYes ? NoRisperdal?Yes ? NoYes ? NoSaphris?Yes ? NoYes ? NoProlixin (fluphenazine)?Yes ? NoYes ? NoSedative/HypnoticsCheck if takenWhen?Dosage?Did it help?Any side effects?Ambien (zolpidem)?Yes ? NoYes ? NoSonata (zaleplon)?Yes ? NoYes ? NoRestoril (temazepam)?Yes ? NoYes ? NoRozerem (ramelteon)?Yes ? NoYes ? NoDesyrel (trazodone)?Yes ? NoYes ? NoLunesta?Yes ? NoYes ? NoBelsomra?Yes ? NoYes ? NoADHD MedicationsCheck if takenWhen?Dosage?Did it help?Any side effects?Adderall (amphetamine)?Yes ? NoYes ? NoConcerta (methylphenidate)?Yes ? NoYes ? NoRitalin (methylphenidate)?Yes ? NoYes ? NoStrattera (atomoxetine)?Yes ? NoYes ? NoVyvanse?Yes ? NoYes ? NoFocalin ?Yes ? NoYes ? NoAntianxiety MedicationsCheck if takenWhen?Dosage?Did it help?Any side effects?Xanax (alprazolam)?Yes ? NoYes ? NoAtivan (lorazepam)?Yes ? NoYes ? NoKlonopin (clonazepam)?Yes ? NoYes ? NoValium (diazepam)?Yes ? NoYes ? NoTranxene (clorazepate)?Yes ? NoYes ? NoBuspar (buspirone)?Yes ? NoYes ? NoPropranolol?Yes ? NoYes ? NoNeurontin (gabapentin)?Yes ? NoYes ? NoOther Medications (specify)Check if takenWhen?Dosage?Did it help?Any side effects??Yes ? NoYes ? No?Yes ? NoYes ? NoAre you currently taking any medications? ??Yes ??NoIf YES, please list name and dose: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Do you currently use tobacco products? ??Yes ??NoIf YES, please list type and how much: ______________________________________________________________________________________________________________________Do you have any medication allergies? ??Yes ??NoIf YES, please list medication and reaction: ______________________________________________________________________________________________________________________Are Immunizations up to date? ??Yes ??NoFamily Psychiatric History Does anyone in your family have mental illness or substance abuse problems? ??Yes ??No If YES, please list who and what their diagnosis is (ex: mother – history of depression): _____________________________________________________________________________________________________________________________________________________________________________________________________________Social History: Developmental and EducationalDid you have any complications after your birth (premature, jaundice, difficulty breathing, etc.)? ??Yes ??NoDid you have any delays or difficulties in reaching the following developmental milestones?None of theseWalkingTalkingToilet training Sleeping aloneBeing away from parentsMaking friendsOTHER:_________________________________________________________________Which options below best describe your childhood home atmosphere?NormalSupportiveParental fightingParental violenceFinancial difficultiesFrequent movingOTHER:_________________________________________________________________Social History: GeneralDo you have a support system/ who? ___________________________________Are you: ??Married ??Significant other ??Divorced (years married: ___) ??SingleIs spirituality/religion important to you? _____________What is your current living situation? ??Live alone ??Live with family ??Live with friends Highest level of education___________________________________________________________Have you ever been in the Military? ??Yes ??NoWhat are your hobbies and interest? _________________________________________________Are you currently employed? ??Yes ??NoIf yes, what is your occupation? ________________Have you ever been a victim of verbal/emotional abuse? ??Yes ??NoHave you ever been a victim of physical abuse? ??Yes ??NoHave you ever been a victim of sexual abuse? ??Yes ??NoHave you ever been in trouble with the law/details________________________________________________________________Social History: Menstruation and PregnancyWhat age did you begin menstruation? _________Do you have any of the following symptoms prior to menstruation?CrampingBloatingMood changesNone of the aboveHave you ever been pregnant????Yes ??NoIf yes, children (ages): _______________________________________________________Have you ever had miscarriages? ??Yes ??NoOver the past 2 weeks, have you been bothered by the following problems?YesNoYesNoLack of energy??Disorganization??Anger and angry episodes??Inattention to tedious tasks??Lack of ability to enjoy things??Loss of necessary items for tasks or activities??Changes in appetite??Easily distracted??Difficulty concentrating??Forgetfulness??Crying spells??Fidgety??Difficulty making decisions??Unnecessarily leaves seat??Excessive worrying??Overactive or restless??Excessive fatigue??Often being noisy??Feeling guilty??Talks excessively??Irritability??Blurts out answers??Decreased sex drive??Can't wait his/her turn??Memory difficulties??Interrupts??Sadness ??Loss of temper??Social isolation/Decrease in socialization??Often touchy??Feelings of worthlessness??Often angry or resentful??Worrying too much??Easily annoyed by others??Feelings of increased muscular tension??Often argues with adults or people in authority??Difficulty sleeping??Often spiteful or vindictive??Attention span is short??Often blames others for his/her mistakes or misbehavior??Trouble listening??Often deliberately annoys people??Ability to finish a task is poor??Often actively defies or refuses to comply with adults' requests or rules??Have you ever experienced periods of:YesNoYesNoIncreased physical activity??Increase in sociability??Decreased sleep and not feeling tired??Talking too fast??Periods of very high self esteem??Talking excessively??Racing thoughts??Highs in mood??Increase in sex drive??Are any of the following symptoms currently present?YesNoYesNoRecurrent dreams of the traumatic event??Dizziness??Flashbacks of the traumatic experience??Experience chest pain or discomfort??Emotional distress when reminded of the traumatic event??Feeling things are not real??Avoid situations that evoke memories of the traumatic event??Sensations of chills or hot flashes??Diminished interest or participation in significant activities??Numbness and tingling??Feeling of detachment or alienation from others has occurred??Trouble interacting, playing with or relating to others??Sense of foreshortened future??Having little or brief eye contact with others??Being watchful or on edge??Not pointing to objects to call attention to them??Startle easily??Unusual or repetitive movements, such as hand flapping, spinning or tapping??Heart palpitations, pounding or fast heart rate??Delays in developmental milestones or loss of milestones already achieved??Anxiety causing you to tremble or shake??Playing with a toy in a way that seems odd or repetitive??Sensations of shortness of breath or of smothering??Not exploring surroundings with curiosity or interest (a child seeming to be in his/her "own world")??Panic attacks are accompanied by sensations of shortness of breath or smothering??Delays in talking?? 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