Adult Patient Intake Form

MINI Patient Health Survey

Patient's Name

Birthdate

Email address

Today's Date

Address

City

State

Zip

Age

Home Phone

Cell Phone

Please list all other persons living in your household, as well as children not living in your home.

Add Additional Name

Primary Care Physician

Address

Phone

By whom were you referred?

Name and Address of your Preferred Pharmacy?

Please describe your reason(s) for seeking treatment at this time (include when the problem started)

Please list other health care professionals

Please indicate past problems with "Past" and current problems with "Current"

Other, Please Explain

Please indicate how the problems are affecting the following areas of you and your life

Relationship with Peers

No effect (1) Little effect (2) Some effect (3) Much effect (4) Significant effect (5) Not Applicable (N/A)

Family

No effect (1) Little effect (2) Some effect (3) Much effect (4) Significant effect (5) Not Applicable (N/A)

Job School Performance

No effect (1) Little effect (2) Some effect (3) Much effect (4) Significant effect (5) Not Applicable (N/A)

Friendships

No effect (1) Little effect (2) Some effect (3) Much effect (4) Significant effect (5) Not Applicable (N/A)

Financial Situation

No effect (1) Little effect (2) Some effect (3) Much effect (4) Significant effect (5) Not Applicable (N/A)

Physical Health

No effect (1) Little effect (2) Some effect (3) Much effect (4) Significant effect (5) Not Applicable (N/A)

Add Additional Treatments

Name

Date

The undersigned patient or responsible party (parent, legal guardian or conservator) consents to, and

authorizes services, by Randall McIntyre These services may include psychotherapy, medication therapy, laboratory tests, diagnostic procedures and other appropriate alternative therapies.

The undersigned understands that he/she has the right to:

Be informed of and participate in the selection of treatment modalities.
Receive a copy of this consent.
Withdraw this consent at any time.

SECTION I

1. Have you been consistently depressed or down, most of the day, nearly every day, for the past two weeks?

Yes No

2. In the past two weeks, have you been less interested in most things or less able to enjoy the things you used to enjoy most of the time?

Yes No

If your answer to both questions above is "NO", please proceed to Section II without answering question 3 below.

3. Over the past two weeks, when you felt depressed or uninterested:

A. Was your appetite decreased or increased nearly every day? Did your weight decrease or increase without trying intentionally (i.e. by ±5% of body weight or 8 lbs or 3.5kg for a 160 lbs kg person in a month)? (If yes to either, please check "YES".

Yes No

B. Did you have trouble sleeping nearly every night (difficulty falling asleep, waking up in the middle of the night, early morning wakening or sleeping excessively)?

Yes No

C. Did you talk or move more slowly than normal or were you fidgety, restless or having trouble sitting still almost every day?

Yes No

D. Did you feel tired or without energy almost every day?

Yes No

E. Did you feel worthless or guilty almost every day?

Yes No

F. Did you have difficulty concentrating or making decisions almost every day?

Yes No

G. Did you repeatedly consider hurting yourself, feel suicidal, or wish that you were dead?

Yes No

SECTION II

1. In the past 12 months, have you had 3 or more alcoholic drinks within a 3 hour period on 3 or more occasions?

Yes No

If your answer to this question is "NO", you have completed section II -please do not answer the questions below. Please proceed to Section Ill.

2. In the past 12 months:

A. Did you need to drink more in order to get the same effect that you got when you first started drinking?

Yes No

B. When you cut down on drinking did your hands shake, did you sweat or feel agitated? Did you drink to avoid these symptoms? (If yes to either, please check "YES".)

Yes No

C. During the times when you drank alcohol, did you end up drinking more than you planned when you started?

Yes No

D. Have you tried to reduce or stop drinking alcohol but failed?

Yes No

E. On the days that you drank, did you spend substantial time in obtaining alcohol, drinking, or in recovering from the effects of alcohol?

Yes No

F. Did you spend less time working, enjoying hobbies, or being with others because of your drinking?

Yes No

G. Have you continued to drink even though you knew that it caused you problems?

Yes No

SECTION III

1. Have you, on more than one occasion, had spells or attacks when you suddenly felt anxious, frightened, uncomfortable or uneasy, even in situations where most people would not feel that way? Did the spells peak within 10 minutes? (If yes to either please check "YES".)

Yes No

2. At any time in the past, did any of those spells or attacks come on unexpectedly or occur in an unpredictable or unprovoked manner?

Yes No

If your answer to both questions above is "NO", please proceed to Section IV without answering any other questions below in Section Ill.

3. Have you ever had one such attack followed by a month or more of persistent fear of having another attack, or worries about the consequences of the attack?

Yes No

4.During the worst spell that you can remember:

A. Did you have skipping, racing or pounding of your heart?

Yes No

B. Did you have sweating or clammy hands?

Yes No

C. Were you trembling or shaking?

Yes No

D. Did you have shortness of breath or difficulty breathing?

Yes No

E. Did you have a choking sensation or a lump in your throat?

Yes No

F. Did you have chest pain, pressure or discomfort?

Yes No

G. Did you have nausea, stomach problems or sudden diarrhea?

Yes No

H. Did you feel dizzy, unsteady, lightheaded or faint?

Yes No

I. Did things around you feel strange, unreal, detached or unfamiliar, or did you feel outside of or detached from, part or all of your body?

Yes No

J. Did you fear that you were losing control or going crazy?

Yes No

K. Did you fear that you were dying?

Yes No

L. Did you have tingling or numbness in parts of your body?

Yes No

M. Did you have hot flushes or chills?

Yes No

5. In the past month, did you have such attacks repeatedly 12 or more) followed by persistent fear of having another attack?

Yes No

SECTION lV

1. In the past month, were you fearful of or embarrassed by being watched or being the focus of attention, or fearful of being humiliated? This includes things like speaking in public, eating in public alone or with others, writing while someone watches, or being in social situations?

Yes No

2. Is this fear excessive or unreasonable?

Yes No

3. Do you fear these situations so much that you avoid them or suffer through them?

Yes No

4. Does this fear disrupt your normal work or social functioning or cause you significant distress?

Yes No

MOOD DISORDER QUESTIONNAIRE

Name

Date of Birth

1. Has there ever been a period of time when you were not your usual self and you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?

Yes No

you were so irritable that you shouted at people or started fights or arguments?

Yes No

you felt much more self-confident than usual?

Yes No

you got much less sleep than usual and found you didn't really miss it?

Yes No

You were much more talkative or spoke faster than usual?

Yes No

thoughts raced through your head or you couldn't slow your mind down?

Yes No

You were so easily distracted by things around you that you had trouble concentrating or staying on track?

Yes No

You had much more energy than usual?

Yes No

you were much more active or did many more things than usual?

Yes No

you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?

Yes No

You were much more interested in sex than usual?

Yes No

You did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?

Yes No

Spending money got you or your family in trouble?

Yes No

2. If you checked YES to more than one of the above, have several of these ever happened during the same period of time?

Yes No

3. How much of a problem did any of these cause you - like being able to work; having family, money, or legal troubles; getting into arguments or fights? Please check 1 response only

No Problem Minor Problem Moderate Problem Serious Problem

4. Have any of your blood relatives (ie, children, siblings, parents, grandparents, aunts, uncles] had manic-depressive illness or bipolar disorder?

Yes No

5. Has a health professional ever told you that you have manic-depressive illness or bipolar disorder?

Yes No

This questionnaire should be used as a starting point. It is not a substitute for a full medical evaluation. Bipolar disorder is a complex illness, and an accurate, thorough diagnosis can only be made through a personal evaluation by your doctor.

Adult ADHD Self-Report Scale (ASRS-v 1.1) Symptom Checklist

Patient's Name

Date

Please answer the questions below, rating yourself on each of the criteria shown using the scale on the right side of the page. As you answer each question, place an X in the box that best describes how you have felt and conducted yourself over the past 6 months. Please give this completed checklist to your·healthcare professional to discuss during today's appointment.

1. How often do you have trouble wrapping up the final details of a project,