Mental Health Intake Form

  • 1 Patient Information
    Do you give permission for ongoing regular updates to be provided to your primary care physician?
  • 2 Current Symptoms
    Please select the symtoms that you have in present
  • 3 Suicide Risk Assessment
    Have you ever had feelings or thoughts that you didn't want to live?
    If YES, please answer the following. If NO, please skip to the next section
    Do you currently feel that you don't want to live?
    How strong is your desire to kill yourself currently? scale of 1 to 10,(ten being strongest)
    Have you ever thought about how you would kill yourself?
    Is the method you would use readily available?
    Have you planned a time for this?
    Is there anything that would stop you from killing yourself?
    Do you feel hope less and/or worthless?
    Have you ever tried to kill or harm yourself before?
    Do you have access to guns?
  • 4 Past Medical History
    List ALL current prescription medications and how often you take them:(if none,write none)
    Have you ever had an EKG?
    How was your EKG?
    For women only:
    Are you currently pregnant or do you think you might be pregnant?
    Are you planning to get pregnant in the near future?
    Do you have any concerns about your physical health that you would like to discuss with us?
  • 5 Personal and Family Medical History
    Have you or your family member ever had suffered from following disease:
    Thyroid
    Anemia
    Liver Disease
    Chronic Fatigue
    Kidney Disease
    Diabetes
    Asthma/respiratory problems
    Stomach or intestinal problems
    Cancer (type)
    Fibromyalgia
    Heart Disease
    Epilepsy orseizures
    Chronic Pain
    HighCholesterol
    Highbloodpressure
    Headtrauma
    Liverproblems
  • 6 Personal and Family Medical History Cont.
    Is there any additional personal or family medical history?
    Past Psychiatric History
    Outpatient treatment
    If yes, Please describe when, by whom, and nature of treatment.
    Psychiatric Hospitalization
    If yes, describe for what reason, when and where.
  • 7 Past Psychiatric Medications

    If you have ever taken any of the following medications, please indicate the dates, dosage, and how helpful they were (if you can't remember all the details, just write in what you do remember)

    Antidepressants
    Prozac(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)
    MoodStabilizers
    Tegretol(carbamazepine)
    Lithium
    Depakote (valproate)
    Lamictal(lamotrigine)
    Tegretol(carbamazepine)
    Topamax(topiramate)
    Antipsychotics/MoodStabilizers
    Seroquel(quetiapine)
    Zyprexa(olanzepine)
    Geodon(ziprasidone)
    Abilify(aripiprazole)
    Clozaril(clozapine)
    Haldol(haloperidol)
    Prolixin(fluphenazine)
    Risperdal (risperidone)
    Sedative/Hypnotics
    Ambien(zolpidem)
    Sonata(zaleplon)
    Rozerem (ramelteon)
    Restoril(temazepam)
    Desyrel(trazodone)
    ADHDmedications
    Adderall
    Concerta(methylphenidate)
    Ritalin (methylphenidate)
    Strattera
    Antianxietymedications
    Xanax(alprazolam)
    Ativan(lorazepam)
    Klonopin(clonazepam)
    Valium(diazepam)
    Tranxene(clorazepate)
    Buspar(buspirone)
  • 8 Your Exercise Level
    Do you exercise regularly?
  • 9 Family Psychiatric History
    Has anyone in your family been diagnosed with or treated for
    Bipolar disorder
    Depression
    Anxiety
    Anger
    Suicide
    Schizophrenia
    Post-traumatic stress
    Alcohol abuse
    Other substance abuse
    Violence
    Has any family member been treated with a psychiatric medication?
  • 10 Substance Use
    Have you ever been treated for alcohol or drug use or abuse?
    Have you ever felt you ought to cut down on your drinking or drug use?
    Have people annoyed you by criticizing your drinking or drug use?
    Have you ever felt bad or guilty about your drinking or drug use?
    Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover?
    Do you think you may have a problem with alcohol or drug use?
    Have you used any street drugs in the past 3 months?
    Have you ever abused prescription medication?
    Check if you have ever tried the following:
    Methamphetamine
    Cocaine
    Stimulants (pills)
    Heroin
    LSD or Hallucinogens
    Marijuana
    Pain killers
    Methadone
    Tranquilizer/sleeping pills
    Alcohol
    Ecstasy
    How many below caffeinated beverages do you drink a day?
    Tobacco History
    How you ever smoked cigarettes?
    Currently smoke?
    Smoke in the past?
    Do you use Pipe, cigars, or chewing tobacco currently?
    Did you use Pipe, cigars, or chewing tobacco in the past?
  • 11 Family Background and Childhood History
    Were you adopted?
    Did your parents' divorce?
    Has any one in your immediate family died?
  • 12 Trauma History
    Do you have a history of being abused emotionally, sexually, physically or by neglect?
  • 13 Educational History
    Did you attend college?
  • 14 Occupational History
    Are you currently?
    Have you ever served in the military?
    Honorable discharge
  • 15 Relationship History and Current Family
    Are you currently?
    If not married, are you currently in a relationship?
    Are you sexually active?
    How would you identify your sexual orientation?
    Have you had any prior marriages?
    Do you have children?
  • 16 Legal History
    Have you ever been arrested?
    Do you have any pending legal problems?
  • 17 Spiritual Life
    Do you belong to a particular religion or spiritual group?
    Do you find your involvement helpful during this illness, or does the involvement make things more difficult or stressful for you?
  • 18 Finish