"Outpatient Adult Psychiatry/Psychology Intake Form - Pacific Pain & Wellness Group"

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Download "Outpatient Adult Psychiatry/Psychology Intake Form - Pacific Pain & Wellness Group"

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23000 Crenshaw Blvd., Suite 100
Torrance, CA 90505
Tel: 310.437.7399 Fax: 424-250-9397
Outpatient Adult Psychiatry/Psychology Intake Form
This form must be filled out in its entirety before coming in for an appointment. Failure to do so may result in your appointment being rescheduled.
Note: You are able to enter your answers directly onto this form.
Name of person completing this section (if different than patient) and relationship to patient:
Click here to enter text.
Patient Information
Name: ___________________
Date of Birth: ___________________
Social Security Number:___________________ ☐
Age:___________________
Will provide at time of apt
Sex: ☐Male ☐Female
Email: ___________________
Which doctor will you be seeing
☐Dr. Ananth
☐Dr. Solomon
Marital Status: ☐Single
☐Married
☐Divorced
☐Separated
☐Widowed
Address: ___________________
Home Phone: ___________________Cell Phone: ___________________
Ethnicity: ___________________
Who were you referred to our clinic by: ___________________
PCP: ___________________
Emergency Contact Name ___________________
Phone ___________________
Relationship: ___________________
*****For all New Patients*****
I understand if I cancel my new patient appointment after the 48 hour cancellation policy or no show/miss my
appointment my card will be charged the full amount of the appointment. ☐ Yes
☐ No
Type or initial name or sign: ___________________
Pharmacy Information
Name of Preferred Pharmacy: ___________________
Pharmacy Address: ___________________
Pharmacy Cross Streets:___________________ & ___________________
Pharmacy City: ___________________
Pharmacy Phone: ___________________
Pharmacy Fax:___________________
1
23000 Crenshaw Blvd., Suite 100
Torrance, CA 90505
Tel: 310.437.7399 Fax: 424-250-9397
Outpatient Adult Psychiatry/Psychology Intake Form
This form must be filled out in its entirety before coming in for an appointment. Failure to do so may result in your appointment being rescheduled.
Note: You are able to enter your answers directly onto this form.
Name of person completing this section (if different than patient) and relationship to patient:
Click here to enter text.
Patient Information
Name: ___________________
Date of Birth: ___________________
Social Security Number:___________________ ☐
Age:___________________
Will provide at time of apt
Sex: ☐Male ☐Female
Email: ___________________
Which doctor will you be seeing
☐Dr. Ananth
☐Dr. Solomon
Marital Status: ☐Single
☐Married
☐Divorced
☐Separated
☐Widowed
Address: ___________________
Home Phone: ___________________Cell Phone: ___________________
Ethnicity: ___________________
Who were you referred to our clinic by: ___________________
PCP: ___________________
Emergency Contact Name ___________________
Phone ___________________
Relationship: ___________________
*****For all New Patients*****
I understand if I cancel my new patient appointment after the 48 hour cancellation policy or no show/miss my
appointment my card will be charged the full amount of the appointment. ☐ Yes
☐ No
Type or initial name or sign: ___________________
Pharmacy Information
Name of Preferred Pharmacy: ___________________
Pharmacy Address: ___________________
Pharmacy Cross Streets:___________________ & ___________________
Pharmacy City: ___________________
Pharmacy Phone: ___________________
Pharmacy Fax:___________________
1
23000 Crenshaw Blvd., Suite 100
Torrance, CA 90505
Tel: 310.437.7399 Fax: 424-250-9397
Patient Name: ____________________________
Please answer the following Questions to the best of your ability, realizing that true and accurate answers are
important to the delivery of quality care. All the information you provide will be kept confidential.
What problems are you having which prompted you to come to this clinic? (Be as thorough as possible)
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
____________
What are you goals/expectations for treatment?
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________
Past Psychiatric Treatment
Have you ever been hospitalized for psychiatric reasons? ☐No
☐Yes
If Yes, when and where? ___________________
Have you ever had outpatient treatment by a psychiatrist? ☐No
☐Yes
If yes, when and by whom? ___________________
Which psychiatric medications have you taken in the past and what were the benefits and/or side affects you
had from them? ☐None List: ___________________
Are you taking any psychiatric medications now? ☐No
☐Yes
Current Medication List – Please list all medications prescribed/otc/and supplements
Medication Name
Dose
Frequency
Are you allergic to any medications? ☐ No
☐ Yes
List medications and allergic reactions: ___________________
Have you undergone any surgical procedures? ☐ No
☐ Yes
Please list procedures & dates of surgery: ___________________
2
23000 Crenshaw Blvd., Suite 100
Torrance, CA 90505
Tel: 310.437.7399 Fax: 424-250-9397
Does your mind work overtime? ☐ No ☐ Yes
Do you have unexplained bursts of energy? ☐ No
☐ Yes
Do you often worry or feel nervous? ☐ No
☐ Yes
Do you have physical symptoms from anxiety? ☐ No
☐ Yes
Do you feel isolated? ☐ No
☐ Yes
Is anyone physically or emotionally abusing you? ☐ No ☐ Yes
How many hours do you get of sleep per night? ☐ 1-3 ☐ 4-6 ☐ 7-10
How many meals do you eat per day? ☐ 1
☐ 2
☐ 3
☐ 4 +
Do you have problems with chronic physical pain? ☐ No
☐ Yes
Rate average pain level: ☐ 1 ☐ 2
☐ 3
☐ 4
☐ 5
☐ 6
☐ 7
☐ 8
☐ 9
☐ 10
Have you ever suffered a severe head injury with loss of consciousness or concussion? ☐ No
☐ Yes
Describe:___________________
What are things that bother you the most – describe.
☐Problems/losses within my family
☐Problems/loses among my friends community
☐educational problems
☐Occupational problems
☐Housing problems
☐Financial/economic problems
☐Can’t get adequate health care
☐Problems with law, legal system
☐Discipline problems at work
☐Careless, high-risk behavior
☐ Other – explain ___________________
Past Medical History:
☐Diabetes
☐Heart Disease
☐Blood pressure
☐Cancer
☐Asthma
☐Emphysema
☐Liver disease
☐Kidney disease
☐Depression
☐Anxiety
☐Ulcers
☐Heart Attack
☐Stroke
☐Heart Palpations
☐Heart Surgery
☐Pace maker implant
☐Cancer
☐Lung Disease
☐Asthma
☐Emphysema
☐Chronic cough
☐Bronchitis
☐Pneumonia
☐Tuberculosis
☐Shortness of breath ☐Seizures
☐Epilepsy
☐Fainting
☐ Vertigo/Dizziness
☐ Motor difficulties
☐ Serious head injuries
☐ Recurring headaches
☐ Arthritis
☐ Muscle cramps
☐ Muscle stiffness
☐ Weakness
☐ Tremors
☐ Numbness
☐ Difficulty walking
☐ Uncontrolled movements
☐ Kidney disease
☐ Thyroid disease
☐ Hormone problems
☐ Blood Disease
☐Other ___________________
3
23000 Crenshaw Blvd., Suite 100
Torrance, CA 90505
Tel: 310.437.7399 Fax: 424-250-9397
☐ Check if none
Alcohol drug and tobacco use
Alcohol ☐ current use: date of last use ___________________
Problems related to use? ☐ No
☐ Yes
Legal, financial, health, relationship) List:___________________
Treatment required? ☐No
☐ Yes
Describe: ___________________
Illicit drug and/or prescription drug abuse (continued on next page)
Substance
Date of last use
Problems related to use
Treatment required
Benzodiazepines
☐ Yes
☐ No
☐ Yes
☐ No
(valium, Xanax, Ativan)
☐ Yes
☐ No
☐ Yes
☐ No
Caffeine
☐ Yes
☐ No
☐ Yes
☐ No
Marijuana
☐ Yes
☐ No
☐ Yes
☐ No
Cocaine
Designer drugs
☐ Yes
☐ No
☐ Yes
☐ No
(Club drugs: G,X)
Hallucinogens
☐ Yes
☐ No
☐ Yes
☐No
(LSD, Mushrooms)
Inhalants
☐ Yes
☐ No
☐ Yes
☐ No
(gasoline, glue, aerosol)
Methamphetamines
☐ Yes
☐ No
☐ Yes
☐ No
(Speed, ice, Ritalin)
Opiates/Methadone
☐ Yes
☐ No
☐ Yes
☐ No
(Vicodin, OxyContin, heroin)
☐ Yes
☐ No
☐ Yes
☐ No
Other
Social History
Where were you born? ___________________
Where did you grow up? ___________________
Did your parents stay together while you were growing up? ☐Yes
☐No
How old were you when they separated? ___________________
Father’s occupation while you were growing up: ___________________
Mother’s occupation while you were growing up: ___________________
Where there any complications at your birth (Premature birth, major medical problems?)
☐No
☐ Yes
Describe: ___________________
Are you/were you a victim of any form of physical/sexual/emotional abuse?
☐ No
☐ Yes
Physical abuse:
Age of occurrence: ___________________
☐ No
☐ Yes
Sexual abuse:
Age of occurrence: ___________________
Emotional abuse: ☐ No
☐ Yes
Age of occurrence: ___________________
4
23000 Crenshaw Blvd., Suite 100
Torrance, CA 90505
Tel: 310.437.7399 Fax: 424-250-9397
Did you graduate from high school? ☐ No
☐ Yes
Last grade attended: ___________________
What type of jobs have you had in the past? ___________________
Are you currently employed? ☐ No
☐ Yes
If yes, where: ___________________
Are you currently involved in a romantic relationship? ☐No
☐ Yes
Spouse’s/partner’s first name: ___________________
How long have you been together? ___________________
How would you describe your relationship? ___________________
What is your spouse’s/partner’s occupation? ___________________
Have you been involved in any previous significant intimate/romantic relationships? ☐ No
☐ Yes
Describe: ___________________
What are some things you enjoy doing (hobbies, sports, past times)? ___________________
Have you ever been convicted of any crimes, incarcerated in prison, or placed on probation?
☐No
☐Yes
Describe: ___________________
Family History
Is there any history of mental illness or substance abuse among your blood relatives?
☐No
☐Yes
If yes, describe – Father’s side: ___________________
Mother’s side: ___________________
Social Supports
Is there anyone your trust or confide in during times of trouble? ☐ No
☐ Yes
Name supports: ___________________
Do you have any religious ties or involvement in a church? ☐ No
☐ Yes
Describe: ___________________
Current living situation
Do you live in a: ☐ House
☐ Apartment
☐ Manufactured Home
☐ other
☐ Own or
☐ Rent
Do you live alone? ☐ Yes
☐ No
If not, who else lives with you: ___________________
Do you have planes to move in the near future? ☐ Yes
☐ No
Where: ___________________
Do you have any pets? ☐ Yes
☐ No
List: ___________________
How many children do you have
___________________ Boys
___________________ Girls
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