"Psychiatric Intake Form - Innovative Psychiatry"

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Andy Mattai, M.D.
9256 Bendix Rd, Suite 200-B
Sonia Heidenreich, LGSW
Columbia, MD 21045
Valerie Middleton, FNP
Phone: 443.542.0773 Fax: 443.542.0931
www.columbiapsychmd.com
Psychiatric Intake Form
Innovative Psychiatry, LLC
Confidential Page
|
1
Andy Mattai, M.D.
9256 Bendix Rd, Suite 200-B
Sonia Heidenreich, LGSW
Columbia, MD 21045
Valerie Middleton, FNP
Phone: 443.542.0773 Fax: 443.542.0931
www.columbiapsychmd.com
Psychiatric Intake Form
Innovative Psychiatry, LLC
Confidential Page
|
1
Psychiatric Intake Form
(All information on this form is strictly confidential)
Please complete all information on this form and bring it to the first visit. It may seem long, but most
of the questions require only a check, so it will go quickly. You may need to ask family members about
the family history. Thank you!
Name______________________________________________________________Date______________
Date of Birth __________________ Primary Care Physician_____________________________________
Current Therapist/Counselor______________________________ Phone_________________________
What are the problem(s) you are seeking help for?
1.___________________________________________________________________________________
2.___________________________________________________________________________________
3.___________________________________________________________________________________
What are your treatment goals?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Current Symptoms Checklist: (check once for any symptoms present, twice for major symptoms)
( ) Depressed mood
( ) Racing thoughts
( ) Excessive worry
( ) Unable to enjoy activities
( ) Impulsivity
( ) Anxiety attacks
( ) Sleep pattern disturbance
( ) Increase risky behavior
( ) Avoidance
( ) Loss of interest
( ) Increased libido
( ) Hallucinations
( ) Concentration/forgetfulness
( ) Decrease need for sleep
( ) Suspiciousness
( ) Change in appetite
( ) Excessive energy
( ) Excessive guilt
( ) Increased irritability
( ) Fatigue
( ) Crying spells
( ) Decreased libido
( ) ________________
Your Medical History:
Allergies_______________________________
Current Weight ____________ Height ____________
List ALL current prescription medications and how often you take them: (if none, write none)
Medication Name
Total Daily Dosage
Estimated Start Date
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Current over-the-counter medications or supplements:
_____________________________________________________________________________________
_____________________________________________________________________________________
Current medical Problems:_______________________________________________________________
_____________________________________________________________________________________
Past medical problems, nonpsychiatric hospitalization or surgeries:
_____________________________________________________________________________________
_____________________________________________________________________________________
Have you ever had an EKG? ( ) Yes ( ) No If yes, when _________ . Was the EKG ( ) normal ( )
abnormal or ( ) unknown?
For women only: Date of last menstrual period ________ Are you currently pregnant or do you think
you might be pregnant? ( ) Yes ( ) No. Are you planning to get pregnant in the near future? ( ) Yes ( )
No Birth control method __________________________ How many times have you been pregnant?
________ How many live births? ________
Do you have any concerns about your physical health that you would like to discuss? ( ) Yes ( ) No
Date and place of last physical exam:_______________________________________________________
Personal and Family Medical History:
You
Family
Which Family Member
Thyroid Disease --------------------- ( )
( )
__________________________
Anemia -------------------------------- ( )
( )
__________________________
Liver Disease ------------------------- ( )
( )
__________________________
Chronic Fatigue --------------------- ( )
( )
__________________________
Kidney Disease ---------------------- ( )
( )
__________________________
Diabetes ------------------------------ ( )
( )
__________________________
Asthma/respiratory problems --- ( )
( )
__________________________
Stomach or intestinal problems - ( )
( )
__________________________
Cancer (type) ------------------------ ( )
( )
__________________________
Fibromyalgia ------------------------- ( )
( )
__________________________
Heart Disease ------------------------ ( )
( )
__________________________
Epilepsy or seizures ----------------- ( )
( )
__________________________
Chronic Pain ------------------------- ( )
( )
__________________________
High Cholesterol -------------------- ( )
( )
__________________________
High blood pressure----------------- ( )
( )
__________________________
Head trauma -------------------------- ( )
( )
__________________________
Liver problems ----------------------- ( )
( )
__________________________
Other ---------------------------------- ( )
( )
__________________________
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Is there any additional personal or family medical history? ( ) Yes ( ) No If yes, please explain below:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
When your mother was pregnant with you, were there any complications during the pregnancy or birth?
_____________________________________________________________________________________
Past Psychiatric History:
Outpatient treatment ( ) Yes ( ) No If yes, Please describe when, by whom, and nature of treatment
Reason
Dates treated
By whom
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Psychiatric Hospitalization ( ) Yes ( ) No If yes, describe for what reason, when and where.
Reason
Date Hospitalized
Where
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Past Psychiatric Medications: If you have ever taken any of the following medications, please indicate
the dates, dosage, and how helpful they were (if you can’t remember all the details, just write in what
you do remember).
Name of Medication
Dates
Dosage
Response/Side-Effects
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Family Psychiatric History:
Has anyone in your family been diagnosed with or treated for:
Bipolar disorder ( ) Yes ( ) No
Schizophrenia
( ) Yes ( ) No
Family Psychiatric History (continued)
Depression
( ) Yes ( ) No
Post-traumatic stress
( ) Yes ( ) No
Anxiety
( ) Yes ( ) No
Alcohol abuse
( ) Yes ( ) No
Anger
( ) Yes ( ) No
Other substance abuse ( ) Yes ( ) No
Suicide
( ) Yes ( ) No
Violence
( ) Yes ( ) No
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If yes, who had what problems?___________________________________________________________
_____________________________________________________________________________________
Has any family member been treated with a psychiatric medication? ( ) Yes ( ) No
If yes, who was treated and what medications and how effective was the treatment?
_____________________________________________________________________________________
_____________________________________________________________________________________
Substance Use:
Have you ever been treated for alcohol or drug use or abuse? ( ) Yes ( ) No
If yes, for which substances? _____________________________________________________________
Where were you treated and when?
_____________________________________________________________________________________
_____________________________________________________________________________________
How many days per week do you drink any alcohol? ____________
What is the least number of drinks you will drink in a day? _______
What is the most number of drinks you will drink in a day? _______
In the past three months, what is the largest amount of alcoholic drinks you have consumed in one day?
___________
Have you ever felt you ought to cut down on your drinking or drug use? ( ) Yes ( ) No
Have people annoyed you by criticizing your drinking or drug use? ( ) Yes ( ) No
Have you ever felt bad or guilty about your drinking or drug use? ( ) Yes ( ) No
Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a
hangover? ( ) Yes ( ) No
Do you think you may have a problem with alcohol or drug use? ( ) Yes ( ) No
Have you used any street drugs in the past 3 months? ( ) Yes ( ) No If yes, which ones?
__________________________________________________________________________
Have you abused prescription medication? ( ) Yes ( ) No
If yes, which ones and for how long_______________________________________________________
_____________________________________________________________________________________
Check if you have ever tried the following:
Yes
No
If yes, how long and when did you last use?
Methamphetamine
( )
( )
_____________________________________________
Cocaine
( )
( )
_____________________________________________
Stimulants (pills)
( )
( )
_____________________________________________
Heroine
( )
( )
_____________________________________________
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