Questionnaire for New Patients

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.

"*" indicates required fields

First Name*

Last Name*

Phone*

Email*

Date*

Social Security Number

Birth Date

Age

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Partner's Name

First Last

If applicable please complete the following:

Partner's Occupation

In 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:

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 gain

Symptoms

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

Reason for seeking help

Name of therapist

Dates of Treatment

Are you CURRENTLY taking PSYCHIATRIC medication?

Yes

Are you CURRENTLY taking NON-PSYCHIATRIC medication?

Yes

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

If yes, please list:

Medication, Dosage, First/Last time you took it, Effect of Medication

Hae you been hospitalized for psychiatric reasons?

Yes

If yes, please describe

Hospital, Dates, Reasons

Have you ever attempted suicide?

Yes

If yes, please describe:

Are you CURRENTLY under treatment for any medical condition?

Yes

If yes, please describe

List any PRIOR illnesses, operations and accidents

FATHER

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 death

How was/is HIS overall health?

If living - Father's Current Age

Father'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 Age

Mother's Occupation

Frequency of Contact with Mother:

Brothers and Sisters

Please 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

Name:

Relationship to you:

Children

Please select any conditions that have been present in your relatives:

Nervous Problems

Depression

Hyperactivity

Counseling

Psychiatric Medication

Psychiatric Hospitalization

Suicide Attempt

Brothers

Please select any conditions that have been present in your relatives:

Nervous Problems

Depression

Hyperactivity

Counseling

Psychiatric Medication

Psychiatric Hospitalization

Suicide Attempt

Sisters

Please select any conditions that have been present in your relatives:

Nervous Problems

Depression

Hyperactivity

Counseling

Psychiatric Medication

Psychiatric Hospitalization

Suicide Attempt

Father

Please select any conditions that have been present in your relatives:

Nervous Problems

Depression

Hyperactivity

Counseling

Psychiatric Medication

Psychiatric Hospitalization

Suicide Attempt

Mother

Please select any conditions that have been present in your relatives:

Nervous Problems

Depression

Hyperactivity

Counseling

Psychiatric Medication

Psychiatric Hospitalization

Suicide Attempt

Aunt/Uncle

Please select any conditions that have been present in your relatives:

Nervous Problems

Depression

Hyperactivity

Counseling

Psychiatric Medication

Psychiatric Hospitalization

Suicide Attempt

Grandparents

Please 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

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

If Yes, please describe briefly:

What type of discharge (separation) did you get?

Are you currently employed?

Yes

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 Leaving

Have you ever been arrested?

Yes

If Yes, please describe:

Do you have a religious affiliation?

Yes

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

If Yes, Age at 1st Use:

Time Since Last Used?

Approximate use in last 30 days?

Cocaine

Yes

If Yes, Age at 1st Use:

Time Since Last Used?

Approximate use in last 30 days?

Crack

Yes

If Yes, Age at 1st Use:

Time Since Last Used?

Approximate use in last 30 days?

Heroin

Yes

If Yes, Age at 1st Use:

Time Since Last Used?

Approximate use in last 30 days?

Methamphetamine

Yes

If Yes, Age at 1st Use:

Time Since Last Used?

Approximate use in last 30 days?

Ecstasy

Yes

If Yes, Age at 1st Use:

Time Since Last Used?

Approximate use in last 30 days?

Which Treatment are You Interested in?*

Medication Management

Talk therapy/Counseling

Psychiatric Evaluation

Is there anything else you would like us to know about you?

Questionnaire for New Patients

Patient Intake Form: Questionnaire for New Patients

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