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Adult Psychiatry Intake Form Name:____________________________________________Date of Birth:__________________________Please complete this form to provide valuable information in advance of your appointment. This information allows for more time to be spent in discussion, counseling on treatment options and coordination of your care. If there is a specific question that you prefer to discuss in person rather than complete on the form please note it with a star and write “discuss in person”. What is(are) the reason(s) you are scheduled for an appointment?__________________________________________________________________________________________________________________________________________________________________________________________________Current Medications: List all medications, supplements, herbals, over-the-counter medications, treatments. **For mental health medications please make notes on the current dose, how long you have been on the medication, if you forget or are unable to take the medication more than twice per month, side effects that you have from the medication, if you feel the medication is helpful or not and any additional information you have. Current MedicationsPrescribed MedicationsSizeDoseFrequencyPrescriber/Side EffectsLipitor(example)40mg1 tabletOnce a dayDr. Med Hills/drowsinessPast Medications:List all past medications you have used. It is helpful if you can include information on when you took it, for how long you were on it, the dose, side effects, if it worked or not and why you stopped it.Below is a list of some more common mental health medications. You can circle any that you know you took, cross out any that you know you did not take and neither circle it nor cross it off if you are not sure. The generic name is listed with the brand name(s) in parentheses. If you have never taken a psychiatric medication you can write “none” in the space below and skip the list. desipramine (Norpramin)amitriptyline (Elavil)nortriptyline (Aventyl, Pamelor)nefazodonefluoxetine (Prozac, Sarafem)bupropion (Wellbutrin)sertraline (Zoloft) paroxetine (Paxil)venlafaxine (Effexor)desvenlafaxine (Pristiq)fluvoxamine (Luvox)mirtazapine (Remeron)citalopram (Celexa)escitalopram (Lexapro)duloxetine (Cymbalta)vilazodone (Viibryd)vortioxetine (Trintellix)levomilnacipran (Fetzima)phenelzine (Nardil)tranylcypromine (Parnate)selegiline (Emsam patch)lithium (Eskaltih, Lithonate)carbamazepine (Tegretol, Equetro)divalproex (Depakote)lamotrigine (Lamictal)oxcarbazepine (Trileptal)methylphenidate (Ritalin, Concerta, Metadate, Methylin, Daytrana patch, Quilivant XR liquid, Jornay PM)dexmethylphenidate (Focalin, Dexedrine)lisdexamphetamine (Vyvanse)d- and l- amphetamine (Adderall)modafinil (Provigil, Sparlon)armodafinil (Nuvigil)amphetamine salts (Mydayis, Evekeo)amphetamine sulfate (Adzenys)atomoxetine (Strattera)clonidine (Catapres, Kapvay)guanfacine (Tenex, Intuniv)chlorpromazine (Thorazine)clozapine (Clozaril)quetiapine (Seroquel)perphenazine (Trilafon)haloperidol (Haldol)risperidone (Risperdal)paliperidone (Invega)olanzapine (Zyprexa)ziprasidone (Geodon)iloperidone (Fanapt)asenapine (Saphris)lurasidone (Latuda)aripiprazole (Abilify)brexpiprazole (Rexulti)cariprazine (Vraylar)diazepam (Valium)chlordiazepoxide (Librium)clonazepam (Klonopin)lorazepam (Ativan)alprazolam (Xanax)buspirone (BuSpar)gabapentin (Neurontin)hydroxyzine (Atarax, Vistaril)propranolol (Inderal)atenolol (Tenormin)guanfacine (Tenex, Intuniv)clonidine (Catapres, Kapvay)pregabalin (Lyrica)prazosin (Minipress)clomipramine (Anafranil)temazepam (Restoril)triazolam (Halcion)zolpidem (Ambien, Intermezzo)zaleplon (Sonata)eszopiclone (Lunesta)ramelteon (Rozerem)doxepin (Silenor)suvorexant (Belsomra)Are you currently seeing a counselor/therapist? If so please list the person’s name, contact information, how long you have been working together and how often you go. ________________________________________________________________________________________________________________________________________________________________________Symptoms:Please review and answer each of the items below. For the items with a box to the left, mark the box according to how you feel. Place an “N” for never having experienced it, a “P” for having experienced it in your past and a “C” for currently experiencing it. You can place a star next to ones that are most significant for you. N = neverP = PastC = Currentdepression poor interestpoor motivation increased appetitedecreased appetitedisrupted sleepsleeping too muchlow energy / fatiguedhaving poor self esteemfeeling worthlessfeeling guiltypoor concentration indecisivehaving a very high self esteemsleep <5 hours/night and not feeling tiredexcessively talkativeracing thoughtsbeyond average risk takinganxious / worriedunable to control anxietyrestless, keyed up, on edgeirritablephysical anxiety (muscle tension, nausea / vomiting, fast heart rate, palpitations, chest pain, shortness of breath, headaches, dizzy, chills, generally feel sickabrupt surges of intense fear/discomfort/anxietyfear of a panic attack happeninghallucinations (seeing, hearing, feeling, smelling, tasting something other people don’t experience)paranoidhistory of traumaintrusive thoughts related to traumaflashbacks to traumaavoidance of things related to the traumaincreased startle responsecareless work mistakespoor attention when trying to pay attention not listening when spoken tonot able to follow instructionsmuch below average organization despite effortexcessively losing thingsunable to stay seated or still for 5 minutesinappropriately interrupting othersrecurrent thoughts / urges / images that are not controllable repetitive behaviors related to urges that cannot be controlled excessively intense ritual behaviorsrestriction in foot intake results in hunger and excess weight lossintense fear of gaining weightdistorted body imageovereating binge eatingintentionally throwing upa lack of control over eating or restricting eatingWhat time do you typically get into bed?_______ What time do you typically try to fall asleep?_______What time do you typically fall asleep?________ How many times do you wake up through the night?______How long are you awake each time?_________ What time do you wake up for the day?_______What time do you get out of bed?__________How many hours of sleep do you need to be rested?________ more than 30 minutes to fall asleep (note how many times per week)waking up in the night and being awake for more than 30 minutes (note how many times per week)waking up more than 30 minutes earlier than desired (note how many times per week)Alcohol1 drink=12-ounce beer/5 oz wine/1 shot liquorHow many drinks do you have per day?01-23-56-910 or moreHave you ever sought treatment for drug or alcohol use?Yes NoHow many drinks do you have per week?01-23-56-910 or moreNo Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?YesNoDrugsWhich drugs have you taken before (check all that apply)?___ Methamphetamines (Speed, Crystal) ___ Cocaine ___ Cannabis (Marijuana, Pot) ___ Ecstasy ___ Tranquilizers (Valium) ___ Hallucinogens (LCD, Mushrooms) ___ Inhalants (Paint Thinner, Aerosol, Glue) ___ Narcotics (Heroin) ___ Barbiturates ___ SyntheticsHow many times in the last year have you used a street drug?NoneA few timesSeveral timesMost daysHow often do you use prescription drugs for non-medical reasonsNot at allSome daysSeveral timesMost daysTobaccoWhich of the following tobacco products have you used in the last year?Smoke cigarettes or cigarsSmoke e-cigarettesDipChewing tobaccoWater pipesHookahsHave often do you smoke/use tobacco?Not at allSome daysMost daysEvery dayDo you need support to quit?YesNoHave you tried to quit tobacco within the last year?YesNoIf yes, how did it go?Are you taking prescription medications other than as prescribed, for a different purpose than prescribed or medication not prescribed directly to you?crave substancesurges to use substancescontinue substance use despite consequencesspend excess resources on substance use or surrounding behaviorssubstance use compromises other roles / work / responsibilities use substances despite potential dangeruse more substances over timehave withdrawal when stopping the substance fear of abandonment in relationshipsunstable relationshipsunstable sense of selferratic behaviorfeeling empty insidereactive mooddifficult to control angerfeeling separated from yourselfPlease list any other things you experience currently and cause you difficulty or concern.________________________________________________________________________________________________________________________________________________________________________Past Psychiatric History:Have you ever had an appointment with a psychiatrist in the past?________________At what age did you first see a psychiatrist?________________Have you been in counseling in the past?__________________Please list past psychiatrists and therapists you have worked with: ________________________________________________________________________________________________________________________________________________________________________Have you ever been hospitalized for a mental health reason?_________________________ If so please provide the year, reason and length of stay:________________________________________Please provide any additional information about your past mental health that would be important to know. ________________________________________________________________________________________________________________________________________________________________________Family Mental Health History: Do you know your family mental health history? Yes / No Please note what mental health conditions exist in your family including any substance use, mental health conditions and/or suicide.________________________________________________________________________________________________________________________________________________________________________Social History:Do you believe in God? Yes / NoDo you have a specific religion? Yes / NoDo you attend a church? Yes / NoAre you married, partnered, single, divorced, widowed, engaged or have another relationship status?Social HistoryWork?Job description: Company or place of work:Marital StatusSingle Divorced WidowedMarried Separated RemarriedWhat is your spouse’s name? (if applicable)Who do you live with?Children’s NamesDo you have any pets? Yes / NoDo you have a gun(s) where you live? Yes / NoMedical History: Please circle current and past medical conditions. Past Medical HistoryHave you been treated for any of the following conditions? Please circle all that apply.CardiovascularLung / ENTBowel/ UrologyBrain/ Nerve/ EyeMusculoskeletalEndocrine/ SkinCancer/ BloodHeart attackHeart failureAtrial fibrillationPalpitationsValve diseaseHeart murmurHypertensionCarotid diseasePVDPassing outCOPDEmphysemaAsthmaSleep apneaPneumoniaLung clot (PE)Positive PPDTMD/ TMJRinging earsAllergiesPancreatitisLiver diseaseReflux/ GERDUlcersColon diseaseColon polypsHemorrhoidsKidney diseaseBladder diseaseLarge prostateChronic headacheStroke/ TIASeizuresMemory lossNeuropathyHerniated discMacular diseaseRetinopathyCataractsGlaucomaMigrains19ArthritisFibromyalgiaGoutOsteoporosisBursitisBack painKnee painShoulder painHip painFoot problemsHigh cholesterolDiabetesThyroid diseaseLow testosteroneMenopauseAcnePsoriasisEczemaSkin cancerHair/ nail diseaseProstate CABreast CACervical CAColon CAAnemiaBleeding disorderDVT/ blood clotTransfusionHepatitis B or CHIV ................
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