Patient Intake Form: Questionnaire for New Patients This questionnaire is for the purpose of getting to know you better in order to provide the best possible mental health services. Please complete this form as honestly and completely as possible. All information that you provide us will be confidential as required by state and federal law. First Name*Last Name*Phone*Email* Date* Social Security NumberBirth DateAgeAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Partner's Name First Last If applicable please complete the following:Partner's OccupationIn your own words, describe the current problems as you see them:How long as this been going on?What made you come in at this time?If you had difficulties in the past, what have you done to cope? Was it helpful?Average hours of sleep per night:Symptoms: Persistent loss of interest in previously enjoyed activities Withdrawing from other people Depressed Mood Rapid mood changes Anxiety Frequent feelings of guilt Difficulty leaving your home Outbursts of anger Spending increased time alone Feeling numb Irritability Panic attacks Avoiding people. places, activities or specific things Repetitive behaviors or mental acts (i.e. counting, checking doors, washing hands Worthlessness Sadness Fear Hopelessness Helplessness Feeling or acting like a different person Please check any symptoms or experiences that you have had in the last month:Fear of certain objects or situations (i.e., flying, heights, bugs)Please describe:Symptoms: Changes in eating/appetite Eating more Voluntary vomiting Excessive exercise to avoid weight gain Eating less Use of laxatives Binge eating Please check any symptoms or experiences that you have had in the last month:Are you trying to lose weight?Weight gainSymptoms Difficulty catching your breath Unusual sweating Increased energy Tremor Frequent worry Racing thoughts Increase muscle tension Easily started, feeling "jumpy" Decreased energy Dizziness Physical sensations others don't have Intrusive memories Difficulty concentrating or thinking Flashbacks Thoughts about harming or killing yourself Large gaps in memory Nightmares Thoughts about harming or killing someone else Feeling as if you were outside yourself, detached, observing what you are doing Feeling puzzled as to what is real and unreal Persistent, repetitive, intrusive thoughts, impulses, or images Unusual visual experiences such as flashes of light, shadows Hear voices when no one else is present Feeling that your thoughts are controlled or placed in your mind Feeling that the television or radio is communicating with you Difficulty problem solving Dependency on others Inappropriate expression of anger Difficulty or inability to say "no" to others Sense of lack of control Abusive relationship Difficulty meeting role expectations Manipulation of others to fulfill your own desires Self-mutilation/cutting Ineffective communication Decreased ability to handle stress Difficulty expressing emotions Concerns about your sexuality Sexual Orientation Heterosexual Homosexual Bisexual I choose not to answer Please describe any other symptoms or experiences you have had problems with:Have you seen a counselor, psychologist, psychiatrist or other mental health professional before? Yes No Reason for seeking helpName of therapistDates of TreatmentAre you CURRENTLY taking PSYCHIATRIC medication? Yes No Are you CURRENTLY taking NON-PSYCHIATRIC medication? Yes No If yes, please list:Medication, Dosage, First/Last time you took it, Effect of medication.Have you been on PSYCHIATRIC medication in the past? Yes No If yes, please list:Medication, Dosage, First/Last time you took it, Effect of MedicationHae you been hospitalized for psychiatric reasons? Yes No If yes, please describeHospital, Dates, ReasonsHave you ever attempted suicide? Yes No If yes, please describe:Are you CURRENTLY under treatment for any medical condition? Yes No If yes, please describeList any PRIOR illnesses, operations and accidentsFATHER Living Deceased If Deceased - Cause of death:If deceased - YOUR age at time of his death:If deceased - FATHER'S age at time of HIS deathHow was/is HIS overall health?If living - Father's Current AgeFather's Occupation:Frequency of contact with Father:MOTHER Living Deceased If deceased - Cause of Death:If deceased - YOUR age at time of her death:If deceased - MOTHER'S age at time of HER death:How was/is HER overall health?If living - Mother's Current AgeMother's OccupationFrequency of Contact with Mother:Brothers and SistersPlease include: Name, Sex, Age, Whereabouts, Are you close to him/her? During your childhood, did you live any significant period of time with anyone other than your natural parents? Yes No Name:Relationship to you:ChildrenPlease select any conditions that have been present in your relatives: Nervous Problems Depression Hyperactivity Counseling Psychiatric Medication Psychiatric Hospitalization Suicide Attempt BrothersPlease select any conditions that have been present in your relatives: Nervous Problems Depression Hyperactivity Counseling Psychiatric Medication Psychiatric Hospitalization Suicide Attempt SistersPlease select any conditions that have been present in your relatives: Nervous Problems Depression Hyperactivity Counseling Psychiatric Medication Psychiatric Hospitalization Suicide Attempt FatherPlease select any conditions that have been present in your relatives: Nervous Problems Depression Hyperactivity Counseling Psychiatric Medication Psychiatric Hospitalization Suicide Attempt MotherPlease select any conditions that have been present in your relatives: Nervous Problems Depression Hyperactivity Counseling Psychiatric Medication Psychiatric Hospitalization Suicide Attempt Aunt/UnclePlease select any conditions that have been present in your relatives: Nervous Problems Depression Hyperactivity Counseling Psychiatric Medication Psychiatric Hospitalization Suicide Attempt GrandparentsPlease select any conditions that have been present in your relatives: Nervous Problems Depression Hyperactivity Counseling Psychiatric Medication Psychiatric Hospitalization Suicide Attempt Have you been married previously? Yes No If Yes, please describe:Highest grade level completed:Degree obtained, if applicable:Did you have any disciplinary problems in school?If you answered Yes to the question above, please explain:Were you considered hyperactive/ADHD in school?If yes, were/are you on any medication?If yes, which medication?How were your grades in school?Have you served in the military? Yes No If Yes, please describe briefly:What type of discharge (separation) did you get?Are you currently employed? Yes No If yes, employer's name:What type of work do you do?Employment History (most recent first)Please include: Type of Job, Dates, Reason for LeavingHave you ever been arrested? Yes No If Yes, please describe:Do you have a religious affiliation? Yes No If Yes, please describe:What kind of social activities do you participate in?Who do you turn to for help with your problems?Have you ever been abused? Verbally Emotionally Physically Sexually Neglected If you selected any of the above please describe:Do you drink alcohol?If yes, age of first use:How much do you drink?How often do you drink?Have you ever passed out from drinking?If Yes, how often?Have you ever blacked out from drinking?If Yes, how often?Have you ever had the "shakes"?Have you ever felt you should cut down on your drinking/drug use?Have people annoyed you by criticizing your drinking/drug use?Have you ever felt bad or guilty about your drinking/drug use?Have you ever drank/used drugs in the morning to steady your nerves or relieve a hangover?Do you use tobacco?If Yes, how often?Marijuana Yes No If Yes, Age at 1st Use:Time Since Last Used?Approximate use in last 30 days?Cocaine Yes No If Yes, Age at 1st Use:Time Since Last Used?Approximate use in last 30 days?Crack Yes No If Yes, Age at 1st Use:Time Since Last Used?Approximate use in last 30 days?Heroin Yes No If Yes, Age at 1st Use:Time Since Last Used?Approximate use in last 30 days?Methamphetamine Yes No If Yes, Age at 1st Use:Time Since Last Used?Approximate use in last 30 days?Ecstasy Yes No If Yes, Age at 1st Use:Time Since Last Used?Approximate use in last 30 days?Which Treatment are You Interested in?* Ketamine TMS/TBS Medication Management Is there anything else you would like us to know about you?
