GARDEN PSYCH



PATIENT REGISTRATION FORMFIRST NAME ______________________ LAST NAME ________________________DOB: ____/______/____________AGE: MARITAL STATUS: Single Married Divorced Widowed SSN: ______ - __________ - ___________ADDRESS: ________________________________________________________ ________________________________________________________EMAIL: ______________________CELL PHONE: ______-________-__________ HOME PHONE: ______-________-__________BEST WAY TO CONTACT YOU(circle one): Email Mobile Phone Home Phone EMEGENCY CONTACT: ______________________ RELATIONSHIP: ______________________ EMERGENCY CONTACT PHONE: ______-________-__________Mental Health Intake Form Please fax or email this a completed version of this form to us 24 hours before the visit. It may seem long, but most of these questions only require a check, so it will go quickly. You may need to ask family members about the family history. This form will help ensure we have a good understanding of your history, so we can help you to the best of our ability. Thank you! Name ___________________________________ Date _______________ Date of Birth__________________ Primary Care Physician (PCP) Name______________________________ PCP Phone: _________________________ Current Psychiatrist/APN/Psychiatric Prescriber Name: _________________________ Phone: __________________ Do you give permission for ongoing regular updates to be provided to the providers listed above? Yes or No Current Therapist/ Counselor _____________________________________ Therapist Phone__________________ What are the problem(s) for which you are seeking help? 1.____________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________What are your personal treatment goals? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ _______________________________________________________________ Current Symptom Checklist: Check once for any symptom present and twice for any major symptoms. ( ) Depressed mood ( ) Racing Thoughts ( ) Excessive worry ( ) Unable to enjoy activities( ) Impulsivity( )Anxiety attacks ( ) Sleep Pattern Disturbance( ) Increase Risky Behavior( ) Avoidance ( ) Loss of Interest ( ) Increased Libido( ) Hallucinations ( ) Concentration/ forgetfulness ( ) Decrease need for sleep( ) Suspiciousness ( ) Change in appetite( ) Excessive Energy ( ) Decreased Libido ( ) Excessive Guilt ( ) Increased Irritability ( )_________________ ( ) Fatigue ( ) Crying Spells ( )_________________Suicide Risk Assessment Have you ever had feelings or thoughts that you didn’t want to live? Yes or NoIf YES, please answer the following question. If NO, please skip to the next section.Do you currently feel that you do not want to live? Yes or NoPast Medical History:Allergies: ___________________________________________ Current Weight: ______________ Height:________List ALL current prescriptions and how often you take them: (if none, write none)Medication NameTotal Daily DosageEstimated Start Date_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Current over-the-counter medications or supplements: ________________________________________________ _____________________________________________________________________________________________Current Medical Problems: _______________________________________________________________________ _____________________________________________________________________________________________Past medical problems, non-psychiatric hospitalization, or surgeries: ______________________________________ _____________________________________________________________________________________________Personal and Family Medical History:You Family Which Family Member?Thyroid Disease --------------------( )( )________________________Anemia--------------------------------( )( )________________________Liver Disease -------------------------( )( )________________________Chronic Fatigue ----------------------( )( )________________________Kidney Disease -----------------------( )( )________________________Diabetes --------------------------------( )( )________________________Asthma/respiratory problems -----( )( )________________________Stomach or intestinal problems ---( )( )________________________Cancer (type) ------------------------( )( )________________________Fibromyalgia --------------------------( )( )________________________Heart Disease -------------------------( )( )________________________Epilepsy or seizures -----------------( )( )________________________Chronic Pain -------------------------( )( )________________________High Cholesterol --------------------( )( )________________________High blood pressure------------------( )( )________________________Head trauma --------------------------( )( )________________________Liver problems -----------------------( )( )________________________Other ----------------------------------( )( )________________________Is there any additional personal or family medical history? Yes or No. If yes, please explain below: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________When your mother was pregnant with you, were there any complications during the pregnancy or birth? Yes or NoIf yes, please explain the circumstances: _________________________________________________________________________________________ __________________________________________________________________________________________Past Psychiatric History:Outpatient Treatment: Yes or No If yes, please describe when, by whom, and nature of the treatment.ReasonDates TreatedBy Whom______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________Psychiatric Hospitalization: Yes or No If yes, please describe for what reason, when and where.ReasonDates HospitalizedWhere__________________________________________________ __________________________________________________________________________________________________________ Past Psychiatric Medications: If you have ever taken any of the following medications, please include the dates, dosage, and how helpful they were. If you cannot remember all the details, just write in what you do remember.DatesDosageResponse/Side EffectsAntidepressantsProzac (fluoxetine)_________________________________________________________Zoloft (sertraline) _________________________________________________________Luvox (fluvoxamine) _________________________________________________________Paxil (paroxetine) _________________________________________________________Celexa (citalopram) _________________________________________________________Lexapro (escitalopram) _________________________________________________________Effexor (venlafaxine) _________________________________________________________Cymbalta (duloxetine) _________________________________________________________Wellbutrin (bupropion) _________________________________________________________Remeron (mirtazapine) _________________________________________________________Serzone (nefazodone) _________________________________________________________Anafranil (clomipramine) _________________________________________________________Pamelor (nortrptyline) _________________________________________________________Tofranil (imipramine) _________________________________________________________Elavil (amitriptyline) _________________________________________________________Pristig (Desvenlafaxine) _________________________________________________________Fetzma (levomilnacipran) _________________________________________________________Savella (milnacipran) _________________________________________________________Britellix (votroxetine) _________________________________________________________Past Psychiatric Medications: (Continued)DatesDosageResponse/Side EffectsViibryd (vilazodone) _________________________________________________________Other_________________________________________________________Mood StabilizersTegretol (carbamazepine) _________________________________________________________Lithium_________________________________________________________Depakote (valproate) _________________________________________________________Lamictal (lamotrigine) _________________________________________________________Topamax (topiramate) _________________________________________________________Neurontin _________________________________________________________Lyrica _________________________________________________________Other _________________________________________________________Antipsychotics/Mood StabilizersSeroquel (quetiapine) _________________________________________________________Zyprexa (olanzepine) _________________________________________________________Geodon (ziprasidone) _________________________________________________________Abilify (aripiprazole) _________________________________________________________Clozaril (clozapine) _________________________________________________________Haldol (haloperidol) _________________________________________________________Prolixin (fluphenazine) _________________________________________________________Risperdal (risperidone) _________________________________________________________Vraylar (cariprazine) _________________________________________________________Sedative/HypnoticsAmbien (zolpidem) _________________________________________________________Sonata (zaleplon) _________________________________________________________Rozerem (ramelteon) _________________________________________________________Restoril (temazepam) _________________________________________________________Desyrel (trazodone) _________________________________________________________Lunesta_________________________________________________________Belsomra_________________________________________________________Triazolam_________________________________________________________Other _________________________________________________________ADHD medications Adderall (amphetamine) _________________________________________________________Concerta (methylphenidate) _________________________________________________________Ritalin (methylphenidate) _________________________________________________________Strattera (atomoxetine) _________________________________________________________Provigil _________________________________________________________Nuvigil _________________________________________________________Vyvanse _________________________________________________________Dexedrine_________________________________________________________Other_________________________________________________________Past Psychiatric Medications: (Continued)DatesDosageResponse/Side EffectsAntianxiety medicationsXanax (alprazolam) _________________________________________________________Ativan (lorazepam) _________________________________________________________Klonopin (clonazepam) _________________________________________________________Valium (diazepam) _________________________________________________________Tranxene (clorazepate) _________________________________________________________Buspar (buspirone) _________________________________________________________Other_________________________________________________________Your Exercise Level:Do you exercise regularly? Yesor NoHow many days a week do you exercise? ______________________How much time each day do you exercise? _____________________What kind of Exercise do you do? _____________________________ Family Psychiatric History:Has anyone in your family been diagnosed with or treated for:Bipolar disorder( ) Yes ( ) NoSchizophrenia( ) Yes ( ) NoDepression( ) Yes ( ) NoPost-traumatic stress( ) Yes ( ) NoAnxiety( ) Yes ( ) NoAlcohol abuse( ) Yes ( ) NoAnger( ) Yes ( ) NoOther substance abuse( ) Yes ( ) NoSuicide( ) Yes ( ) NoViolence( ) Yes ( ) NoIf yes, who had each problem? _______________________________________________________________ __________________________________________________________________________________________Has any family member been treated with a psychiatric medication? ( ) Yes ( ) NoIf yes, who was treated, what medications did they take, and how effective was the treatment? ___________________________________________________________________________________________ ___________________________________________________________________________________________ Substance Use:Have you ever been treated for alcohol or drug use or abuse? ( ) Yes ( ) NoIf yes, for which substances? __________________________________________________________________If yes, where were you treated and when? ________________________________________________________ __________________________________________________________________________________________How many days per week do you drink any alcohol? ____________What is the least number of drinks you will drink in a day? _______What is the most number of drinks you will drink in a day? _______In the past three months, what is the largest amount of alcoholic drinks you have consumed in one day? ______Have you ever felt you ought to cut down on your drinking or drug use? ( ) Yes ( ) NoHave people annoyed you by criticizing your drinking or drug use? ( ) Yes ( ) NoHave you ever felt bad or guilty about your drinking or drug use? ( ) Yes ( ) NoDo you think you may have a problem with alcohol or drug use? ( ) Yes ( ) NoHave you used any street drugs in the past 3 months? ( ) Yes ( ) NoIf yes, which ones? __________________________________________________________________________Have you ever abused prescription medication? ( ) Yes ( ) NoIf yes, which ones and for how long? ____________________________________________________________ __________________________________________________________________________________________Check if you have ever tried any of the following:YesNoIf yes, for how long and when did you last use?Methamphetamine( )( )______________________________________Cocaine( )( )______________________________________Stimulants (pills) ( )( )______________________________________Heroin( )( )______________________________________LSD or Hallucinogens( )( )______________________________________Marijuana( )( )______________________________________Pain Killers (not as prescribed) ( )( )______________________________________Methadone( )( )______________________________________Tranquilizer/sleeping pills( )( )______________________________________Alcohol( )( )______________________________________Ecstasy( )( )______________________________________Other( )( )______________________________________ How many caffeinated beverages do you drink a day? Coffee ______ Sodas _______ Tea_________ Tobacco History:How you ever smoked cigarettes? ( ) Yes ( ) NoCurrently? ( ) Yes ( ) NoHow many packs per day on average? ___________ How many years? _________Family Background and Childhood History: Were you adopted? ( ) Yes ( ) NoWhere did you grow up? _________________________________List your siblings and their ages: _______________________________________________________________ __________________________________________________________________________________________Did your parents' divorce? ( ) Yes ( ) No If so, how old were you when they divorced? __________________If your parents divorced, who did you live with?___________________________________________________Describe your father and your relationship with him: _________________________________________________________________________________________________________________________________________Describe your mother and your relationship with her: ________________________________________________________________________________________________________________________________________Trauma History:Do you have a history of being abused emotionally, sexually, physically or by neglect? ( ) Yes ( ) No.Please describe when, where and by whom: ______________________________________________________ ___________________________________________________________________________________________Educational History:Highest Grade Completed? __________ Where? _________________________________Did you attend college? ________ Where? ________________________Major? _________________________What is your highest educational level or degree attained? __________________________________________Occupational History:Are you currently: ( ) Working ( ) Student ( ) Unemployed ( ) Disabled ( ) RetiredHow long in present position? _______________________________________________What is/was your occupation? ___________________________________________________Where do you work? _______________________________________________________Have you ever served in the military? _______ If so, what branch and when? ____________________________Honorable discharge ( ) Yes ( ) No Other type discharge _____________________________________________Relationship History and Current Family:Are you currently: ( ) Married ( ) Partnered ( ) Divorced ( ) Single ( ) Widowed How long? _____ If not married, are you currently in a relationship? ( ) Yes ( ) No If yes, how long? ___________________How would you identify your sexual orientation? ( ) straight/heterosexual ( ) lesbian/gay/homosexual ( ) bisexual ( ) transsexual ( ) unsure/questioning ( ) asexual ( ) other ( ) prefer not to answerDescribe your relationship with your spouse or significant other: __________________________________________________________________________________________Have you had any prior marriages? ( ) Yes ( ) No. If so, how many? ________________Do you have children? ( ) Yes ( ) No If yes, list ages and gender: _____________________________________________________________________________________________________________________________Describe your relationship with your children: ____________________________________________________List everyone who currently lives with you: _________________________________________________________________________________________________________________________________________________Legal History: Have you ever been arrested? _______Do you have any pending legal problems? _______________Spiritual Life:Do you belong to a religion or spiritual group? ( ) Yes ( ) NoIf yes, what is the level of your involvement? _____________________________ Is there anything else that you would like us to know? ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Signature_________________________________________________Date_____________________________ ................
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