Your Psychiatric History:



PATIENT’S NAME:

YOUR MAIN COMPLAINT: (Please circle all that applies)

Anxiety/Panic Depression Mood swings Attention Problems Addiction

MEDICAL HISTORY: (Please be truthful 100% - Put checkmarks in the table):

|Condition |Yes |No |Comments –treated in hospital, which drug/meds used |

| |Check |Check |etc |

|Diabetes | | | |

|High Blood Pressure | | | |

|Thyroid Problems | | | |

|Weight Loss (Anorexia) | | | |

|Weight Gain (Obesity) | | | |

|Cancer | | | |

|Asthma | | | |

|Seizures | | | |

|Head Injury | | | |

|Pain | | | |

|Sex Problems | | | |

|Bladder Problems | | | |

|Surgeries | | | |

|Are you pregnant now? | | | |

PSYCHIATRIC HISTORY: (Please be truthful 100% - Put checkmarks in the table):

|Condition |Yes |No |Comments –treated in hospital, which drug/meds used |

| |Check |Check |etc |

|DEPRESSION | | | |

|BIPOLAR-MANIA | | | |

|SCHIZOPHRENIA | | | |

|PSYCHOSIS | | | |

|ANXIETY PANIC | | | |

|ADHD | | | |

|ALCOHOL PROBLEMS | | |DWI? DUI? |

|DRUG PROBLEMS | | | |

|EATING DISORDERS | | | |

|SUICIDE ATTEMPTS | | |How many attempts: |

Who is prescribing Psychiatric Medications to you at this time? _________________

Has your personal doctor (PCP) ever referred you to a Psychiatrist? Yes No

If you attempted suicide, how many times? ____________

How did you attempt suicide: Overdose – Cutting on me – Attempted to use gun

Used drugs or alcohol – Other method ________________________

Who saved you from above attempt? I quit the attempt – I called someone

Someone found me – Something else happened.

Were you using drugs or alcohol during the suicide attempt? Yes. No.

Were you treated after attempt? Yes. No. If yes, who treated you?

Where were you treated?

Have you ever attempted to harm any one else in past?

Have you been abused in the past? If yes, tell us how you were abused and by whom?

OTHER PSYCHIATRIC HISTORY (Please describe):

LIST YOUR ALLERGIES BELOW:

|MEDICINE |ALLERGIC YES OR NO |Circle Names of All Psychiatric meds you are allergic to: |

|Penicillin | | |

|Sulfa | | |

|Antibiotics | | |

|Aspirin | |Other Allergies | |

|Tylenol | | | |

CIRCLE ALL PSYCHIATRIC MEDICINES THAT DID NOT WORK FOR YOU:

Prozac, Zoloft, Celexa, Lexapro, Luvox, Cymbalta, Effexor, Pristiq, Seroquel, Zyprexa, Geodone, Depakote, Tegretol, Lamictal, Trileptal, Lyrica, Gabapentin

LIST YOUR CURRENT MEDICATIONS:

|NAME OF MEDICATION |DOSE |HOW FREQUENT |SIDE EFFECTS? |COMMENTS |

| | | | | |

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FAMILY PSYCHIATRIC HISTORY: Please put check marks in the table)

| |Depression |Bipolar |Anxiety |Alcohol Abuse |Drug Abuse |ADHD |Suicide |

|Dad | | | | | | | |

|Mom | | | | | | | |

|Siblings | | | | | | | |

|Grandfather | | | | | | | |

|Grandmother | | | | | | | |

|Children | | | | | | | |

Have you or any one in the family got a bad temper?

Has any one in your family been accused by the law of DWI or DUI, or temper problems? (please describe):

SOCIAL HISTORY:

Which town you were born in? __________________

Where did you grow up? _______________________

Circle the following as it pertains to you:

Marital Status:

Single, Married, Separated, Divorced, Widowed, Significant Other

How many times you have been married? ______

With whom do you live? _____________________________

Habits (cups or cans in a day):

Coffee _____ Tea _____ Colas ___ per day. I mostly/only drink water.

Alcohol (Circle) : Never. Less than 1 drink/beer per week. 1-5 per week. More than 5 per week. Please describe your CURRENT alcohol use:

Drugs Used in Past: Never used.

Marijuana Cocaine Methamphetamines LSD Ecstasy Mushrooms

Inhalants-gas/spray Please describe your PAST drug use:

Drugs Used Now: None.

Marijuana Cocaine Methamphetamines LSD Ecstacy Mushrooms

Inhalants-gas/spray Please describe your CURRENT drug use:

Tobacco:

Cigarettes: Never. Quit __ years ago. Still smoke___ per day for __Years.

Employed? Full Time Part Time I am at home. I am a student.

Please describe your job: ___________________________________

________________________________________________________

Education:

Are you a student? ____ where________________

Finished Grade School _____ College _____ Postgraduate _________

Safety: Do you wear seatbelts? All the time. Sometimes. Never.

Do you use cane/walker? All the time. Sometimes. Never.

Do you wear “Emergency Call Device?” Yes. No.

Do you know how to use “911” service? Yes. No.

Do you have a living will? Yes. No.

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