Adult Intake Form

Date

Name:

Age:

Address:

Home phone:

Work phone:

Cell phone:

What issue(s) bring(s) you to the Psychiatry Clinic?

What has been stressing you of late (e.g. Family, job, recent loss of loved ones, financial issues)?

Past Psychiatric Care

Have you been ever diagnosed with a mental health condition by a medical provider (e.g. Depression, bipolar, schizophrenia, ADHD)? If so, please list.

Date seen:

By whom:

For what problem?

What treatment (meds, ECT, therapy)?

Add New Entry

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

Date(s):

Where and for what?

What treatment (meds, ECT, therapy)?

Add New Entry

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

Good/bad effects:

Ambien

Good/bad effects:

Adderall

Good/bad effects:

Anafranil

Good/bad effects:

Antabuse

Good/bad effects:

Ascendin

Good/bad effects:

Atarax

Good/bad effects:

Ativan

Good/bad effects:

Buspar

Good/bad effects:

Campral

Good/bad effects:

Celexa

Good/bad effects:

Chloral hydrate

Good/bad effects:

Clozaril

Good/bad effects:

Cogentin

Good/bad effects:

Concerta

Good/bad effects:

Cymbalta

Good/bad effects:

Dalmane

Good/bad effects:

Depakote

Good/bad effects:

Dexedrine

Good/bad effects:

Doral

Good/bad effects:

Effexor

Good/bad effects:

Elavil

Good/bad effects:

Fanapt

Good/bad effects:

Geodon

Good/bad effects:

Halcion

Good/bad effects:

Haldol

Good/bad effects:

Klonopin

Good/bad effects:

Invega

Good/bad effects:

Lamictal

Good/bad effects:

Latuda

Good/bad effects:

Lexapro

Good/bad effects:

Librium

Good/bad effects:

Lithium

Good/bad effects:

Lunesta

Good/bad effects:

Luvox

Good/bad effects:

Marplan

Good/bad effects:

Mellaril

Good/bad effects:

Methadone

Good/bad effects:

Miltown

Good/bad effects:

Nardil

Good/bad effects:

Norpramine

Good/bad effects:

Orap

Good/bad effects:

Pamelor

Good/bad effects:

Parnate

Good/bad effects:

Paxil

Good/bad effects:

Prosom

Good/bad effects:

Prolixin

Good/bad effects:

Remeron

Good/bad effects:

Restoril

Good/bad effects:

Risperdal

Short text field

Ritalin

Good/bad effects:

Saphris

Good/bad effects:

Serax

Good/bad effects:

Seroquel

Good/bad effects:

Serzone

Good/bad effects:

Soma

Good/bad effects:

Sonata

Good/bad effects:

Stelazine

Good/bad effects:

Strattera

Good/bad effects:

Suboxone/subutex

Good/bad effects:

Symmetrel

Good/bad effects:

Tegretol

Good/bad effects:

Thorazine

Good/bad effects:

Tofranil

Good/bad effects:

Topomax

Good/bad effects:

Traxene

Good/bad effects:

Trazodone

Good/bad effects:

Trileptal

Good/bad effects:

Valium

Good/bad effects:

Vibryd

Good/bad effects:

Vistraril

Good/bad effects:

Vivitrol

Good/bad effects:

Wellbutrin

Good/bad effects:

Xanax

Good/bad effects:

Zoloft

Good/bad effects:

Zyprexa

Good/bad effects:

Any other psychiatric medications you have taken?

Past Medical Care

Do you have a primary care doctor?

Yes No

Name:

Last Seen?

What medical illnesses do you have?

What surgeries have you had?

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

Medication:

Dosage:

# times per day:

For what condition:

Who prescribes it:

Add New Entry

Describe any allergies you have (e.g. to medications, foods).

For women

Last menstrual period?

Usually regular?

Yes No

Do you use any birth control?

Yes No

If yes, please list.

Have you been pregnant before?

Yes No

If yes, how many times?

Miscarriages?

Yes No

Elective abortions?

Yes No

Any depression or unreal thoughts around pregnancies?

Yes No

Substance Use History

How often have you used the following substances?

Tobacco

Last time used?

Approximately how often (# of times per week, month or year)?

How much do you use in a sitting if/when you do use?

Alcohol

Last time used?

Approximately how often (# of times per week, month or year)?

How much do you use in a sitting if/when you do use?

Marijuana or K2/"spice"

Last time used?

Approximately how often (# of times per week, month or year)?

How much do you use in a sitting if/when you do use?

Cocaine

Last time used?

Approximately how often (# of times per week, month or year)?

How much do you use in a sitting if/when you do use?

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

Last time used?

Approximately how often (# of times per week, month or year)?

How much do you use in a sitting if/when you do use?

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

Last time used?

Approximately how often (# of times per week, month or year)?

How much do you use in a sitting if/when you do use?

PCP or LSD

Last time used?

Approximately how often (# of times per week, month or year)?

How much do you use in a sitting if/when you do use?

Mushrooms

Last time used?

Approximately how often (# of times per week, month or year)?

How much do you use in a sitting if/when you do use?

Others

Last time used?

Approximately how often (# of times per week, month or year)?

How much do you use in a sitting if/when you do use?