Today's Date:

Name:

Birthdate:

Age:

Sex:
F M

How did you hear about this clinic?

Describe briefly your present symptoms:

Please list the names of other practitioners you have seen for this problem:

Psychiatric Hospitalizations (include where, when, & for what reason):

Have you ever had ECT? Y N

Have you had psychotherapy? Y N

Current Medications

Drug Allergies: N Y

To what?

Please list any medications that you are now taking. Include non-prescription medications & vitamins or supplements:

1. Name of drug: (if none, type "none")

Dose (strength & number of pills per day): (if none, type "none")

Reason: (if none, type "none")

How long have you been taking this? (if none, type "none")

2. Name of drug:

Dose (strength & number of pills per day):

Reason:

How long have you been taking this?

3. Name of drug:

Dose (strength & number of pills per day):

Reason:

How long have you been taking this?

4. Name of drug:

Dose (strength & number of pills per day):

Reason:

How long have you been taking this?

5. Name of drug:

Dose (strength & number of pills per day):

Reason:

How long have you been taking this?

6. Name of drug:

Dose (strength & number of pills per day):

Reason:

How long have you been taking this?

7. Name of drug:

Dose (strength & number of pills per day):

Reason:

How long have you been taking this?

8. Name of drug:

Dose (strength & number of pills per day):

Reason:

How long have you been taking this?

What Psychiatric Medications have you taken in the PAST?

1. Name: (if none, type "none")

Dosage: (if none, type "none")Reason: (if none, type "none")

When did you start it? (if none, type "none")When did you stop it? (if none, type "none")

Why did you stop it? (if none, type "none")

2. Name:

Dosage: Reason:

When did you start it? When did you stop it?

Why did you stop it?

3. Name:

Dosage: Reason:

When did you start it? When did you stop it?

Why did you stop it?

4. Name:

Dosage: Reason:

When did you start it? When did you stop it?

Why did you stop it?

5. Name:

Dosage: Reason:

When did you start it? When did you stop it?

Why did you stop it?

6. Name:

Dosage: Reason:

When did you start it? When did you stop it?

Why did you stop it?

PAST MEDICAL HISTORY

Do you now or have you ever had:

Diabetes

Heart murmur

Crohn's disease

High blood pressure

Pneumonia

Colitis

High cholesterol

Pulmonary embolism

Anemia

Hypothyroidism

Asthma

Jaundice

Goiter

Emphysema

Hepatitis

Cancer - Type:

Stroke

Stomach or peptic ulcer

Leukemia

Epilepsy (seizures)

Rheumatic fever

Psoriasis

Cataracts

Tuberculosis

Angina

Kidney disease

HIV/AIDS

Heart problems

Kidney stones

Other medical conditions (please list):

PERSONAL HISTORY

What is your highest education? High school Some college College graduate Advanced degree

What is your current or past occupation?

Do you receive disability or SSI? Yes No

If yes, for what disability & how long?

Have you ever had legal problems? (specify)

Religion:

FAMILY HISTORY

FATHER:
Age (IF LIVING)

Health & Psychiatric (IF LIVING)

Age at death (IF DECEASED)

Cause (IF DECEASED)

MOTHER:
Age (IF LIVING)

Health & Psychiatric (IF LIVING)

Age at death (IF DECEASED)

Cause (IF DECEASED)

SIBLINGS:
Age(s) (IF LIVING) Age(s) (IF LIVING)

Health & Psychiatric (IF LIVING) Health & Psychiatric (IF LIVING)

Age at death (IF DECEASED) Age at death (IF DECEASED)

Cause (IF DECEASED) Cause (IF DECEASED)

CHILDREN:
Age(s) (IF LIVING) Age(s) (IF LIVING)

Health & Psychiatric (IF LIVING) Health & Psychiatric (IF LIVING)

Age at death (IF DECEASED) Age at death (IF DECEASED)

Cause (IF DECEASED) Cause (IF DECEASED)

EXTENDED FAMILY PSYCHIATRIC PROBLEMS PAST & PRESENT:

Maternal Relatives:

Paternal Relatives:

SYSTEMS REVIEW

In the past month, have you had any of the following problems?

Are you sexually active? Yes No

If yes, what type of birth control do you use?

SUBSTANCE USE
(by drug category) (select all that apply and answer corresponding questions)

ALCOHOL

Age when you first used this: How much & how often did you use this?

How many years did you use this? When did you last use this?