Adult Intake Form

AMS Psychiatry

Please correct the errors described below.

Past Psychiatric Care

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Have you ever been hospitalized for psychiatric care? Please list and describe.

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Have you ever been treated with any of the following medications? Circle all that apply and list any good or bad effects of the medications.

Abilify

Ambien

Adderall

Anafranil

Antabuse

Ascendin

Atarax

Ativan

Buspar

Campral

Celexa

Chloral hydrate

Clozaril

Cogentin

Concerta

Cymbalta

Dalmane

Depakote

Dexedrine

Doral

Effexor

Elavil

Fanapt

Geodon

Halcion

Haldol

Klonopin

Invega

Lamictal

Latuda

Lexapro

Librium

Lithium

Lunesta

Luvox

Marplan

Mellaril

Methadone

Miltown

Nardil

Norpramine

Orap

Pamelor

Parnate

Paxil

Prosom

Prolixin

Remeron

Restoril

Risperdal

Ritalin

Saphris

Serax

Seroquel

Serzone

Soma

Sonata

Stelazine

Strattera

Suboxone/subutex

Symmetrel

Tegretol

Thorazine

Tofranil

Topomax

Traxene

Trazodone

Trileptal

Valium

Vibryd

Vistraril

Vivitrol

Wellbutrin

Xanax

Zoloft

Zyprexa

Past Medical Care

Please list all medications you are currently taking, including over-the-counter medications, herbals, and supplements.

Add New Entry

For women

Substance Use History

How often have you used the following substances?

Tobacco

Alcohol

Marijuana or K2/"spice"

Cocaine

Opiates (e.g. Heroin, morphine, Percocet, 5 oxycodone, Tylenol #3, Dilaudid/hydromorphone)

Tranquilizers/sedatives (e.g. Xanax, Ativan, Klonopin, Valium)

PCP or LSD

Mushrooms

Others

Family History

Please list blood relatives who have been diagnosed with the following conditions.

Social History

Safety

PATIENT HEALTH QUESTIONNAIRE (PHQ-9)

Over the last 2 weeks. how often have you been bothered by any of the following problems?

  • 0 - Not at all
  • 1 - Several days
  • 2 - More than half the days
  • 3 - Nearly everyday
(Healthcare professional: For interpretation of TOTAL, please refer to accompanying the scoring card.)

PHQ-9 is adapted from PRIME MD TODAY, developed by Drs Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke, and colleagues, with an educational grant from Pfizer Inc. For research information, contact Dr. Spitzer at rls8@columbia.edu. Use of the PHQ-9 may only be made in accordance with the Terms of Use available at http://www.pfizer.com.Copyright © 1999 Pfizerlnc.Allrightsreserved. PRIME MD TODAY is a trademark of Pfizer Inc.

ZT274388

The Epworth Sleepiness Scale (ESS)

How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation:

  • 0 - would never doze
  • 1 - slight chance of dozing
  • 2 - moderate chance of dozing
  • 3 - high chance of dozing

SCORE RESULTS:

  • 1-6: Congratulations, you are getting enough sleep!
  • 7-8: Your score is average
  • 9 and up: Very sleepy and should seek medical advice

Johns, M.W. (1991). A new method for measuring daytime sleepiness: The Epworth sleepiness scale. Sleep, 14, 540-545. Permission for single-use of the information contained in this material was obtained from the Associated Professional Sleep Societies, LLC, September 2006.

Copyright © MW Johns 1990-1997. Used under license.

CHECKLIST: Review of Systems

CONSTITUTIONAL

EYES:

EAR,NOSE,THROAT:

CARDIOVASCULAR:

ENDOCRINE:

RESPIRATORY:

GASTROINTESTINAL:

GENITOURINARY:

ALLERGIC/IMMUNOLOGIC:

PSYCHIATRIC:

HEMATOLOGY/LYMPH:

MUSCULOSKELETAL:

SKIN:

NEUROLOGICAL:

FEMALES ONLY:

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