New Patient Medical Review & Consent

Emergency Assistance

If this is an emergency, call:

Crisis Line: (XXX) XXX-XXXX
911

SECTION #1 OUTPATIENT INFORMATION

Patient Information

First name

Last name

Date of birth

Gender

Phone number

Social Security Number

Email address

If you are a student, what is your grade level?

If a minor, who lives with you?

Who referred you?

Contact Information

Home Address

Place of Employment

Position

Pharmacy Name

Pharmacy Phone Number

Pharmacy Fax #

Primary Care Physician Name

PCP Phone number

PCP Fax #

Please select all ways we can contact you

Phone

Text

voicemail

If no, what is your preferred method of communication?

Billing Information

Primary Insurance:

Primary Insurance ID #

Primary Group #

Upload a photo of your insurance card

Add file

Please upload a file

Seconday Insurance:

Secondary Insurance ID #

Secondary Group #

Upload a photo of your secondary insurance card

Add file

Please upload a file

Responsible Party/Primary Insured Name:

Date of birth

Gender

Insured Home Address

Insured Email address

IF THE PATIENT IS A MINOR, PLEASE LIST NAMES OF PARENTS AND OTHER CARETAKERS:
(please indicate relationship, i.e. bio-parent, stepparent, legal guardian, etc.)

Contact Name

Phone Number

Contact Name

Phone Number

Add another Caretaker

Add a new caretaker contact

Emergency Contact

First name

Last name

Phone number

Relationship

Add another Contact

In case of an emergency, do we have permissions to contact this person?

Yes No

Add another emergency contact

** I believe the above information to be true to the best of my knowledge and understand that it is my responsibility to update any changes. ** I release Davenport Behavioral Center, LLC. to make contact with any of the above listed emergency contacts in situations that are deemed an emergency, and understand that the contacts are to coordinate access to emergency care.

Type Name Signature

Date

Signature of Patient or Legal Guardian

Relationship to Patient

SECTION #2 - MEDICAL REVIEW OF SYSTEMS

Patient Name

Date of Birth

Age

Name of person who completed this form

Review of systems

In each area, if you are not having any difficulties, please check "No Problems." If you are experiencing any of the symptoms listed, please mark the ones that apply, or explain any that may not be listed.

Constitutional

No problems

lack of energy

unexplained weight gain or weight loss

loss of appetite

fever

night sweats

pain in jaws when eating

scalp tenderness

prior diagnosis of cancer

Heart & Blood Vessels:

No problems

irregular heartbeat

racing heart

chest pains,

swelling of feet or legs

pain in legs with walking

Kidney & Bladder:

No problems

painful urination

frequent urination Urgency

prostate problems

bladder problems

impotence

Muscles, Bones, Joints:

No problems

joint pain

aching muscles

shoulder pain

swelling of joints

joint deformities

back pain

Skin, Hair & Breast:

No problems

persistent rash

itching

new skin lesion

change in existing skin lesion

hair loss or increase

breast changes

Endocrine/Development:

No problems

intolerance to heat or cold

frequent hunger/urination; thirst

changes in sex drive

motor delays

speech delay

developmental delay

Males:

No problems

Scrotal pain,

testicle lump or swelling

impotence (weak erection)

inability to ejaculate or orgasm

abnormal penis discharge

Females:

No problems

no menses

menstrual irregularity,

painful or heavy periods

premenstrual moodiness /irritability /tension

infertility

Age of first period

Blood/Lymph

No problems

easy bleeding

easy bruising

anemia

abnormal blood tests

leukemia

unexplained swollen areas

Allergic /Immunologic:

No problems

seasonal allergies

hay fever symptoms

itching

frequent infections

exposure to HIV

exposure to immune suppressant medications

Habits

Have you ever smoked?

Yes No

If current use, how much?

Have you ever used alcohol?

Yes No

If current use, how much?

Have you ever used recreational substances?

Yes No

If current use, how much?

Reason for today's visit

What is the reason for the visit?

Duration of the condition(s)

Triggers/Stressors

Have you previously been prescribed psychiatric medication?

Yes No

If yes, what medications are you currently taking?

List the name of the prescribing physician

Please list any non-psychiatric medication

Do you have any Allergies or pre-existing medical conditions?

Have you had any surgeries? (Please List)

Severe Head Injuries, Loss of Consciousness or Seizures?

Yes No

Are you on medical leave?

Yes No

by whom/when?

Are you in counseling?

Yes No

Name of counselor

Previous history of counseling:

List all psychiatric hospitalizations and dates:

History of physical abuse?

Yes No

History of sexual abuse / molestation:

Yes No

History of domestic violence?

Yes No

History of legal problems?

Yes No

Are you on Probation?

Yes No

Parents divorced?

Yes No

How many siblings? (Brothers)

How many siblings? (sisters)

Your birth order

Do you have children?

Yes No

If so, please list sex and ages

Is there anything else regarding your medical history that we should be aware of?

Typed Name (signature)

Date

Your information will be encrypted.