Transcription
THE CENTER FOR ANXIETY AND DEPRESSIONMedical History FormPlease answer these questions as completely as you can. We realize that this form is long, but theinformation in this form will be extremely valuable to us in providing you the best possible care.Today’s Date: Patient's Name:LastFirstMiddlePatient's Date of Birth: Age Patient's Gender: M F Race:Month/Day/YearContact Address:Street or PO BoxCity/State/ZipContact Phone Number: Alternate Phone Number:(Optional)Emergency Contact:NameNumber:RelationshipWho referred you to the clinic?Doctor or Clinic name, Therapist name, “Word of Mouth,” “Internet,” “Family Member,” etc.Current Medications You Take: (all medications)NameDosageHow often every day?How long have you been taking it?Medication Allergies and Reactions:Please do not leave blank, write “none” if no allergies.What Psychiatric Medications have you taken in the PAST:NameDosageWhen did you start it?When did you stop it?Why did you stop it?
THE CENTER FOR ANXIETY AND DEPRESSIONMedical History FormWhat are your current emotional or mental-health concerns?(If you wish, you may rank them in order of severity, with 1 being most important, and 2 or 3 as a lesser concern to you.)ANXIETYAGITATIONADDICTIONSPanic attacksRestlessnessOveruse of alcoholSituational worry (“stress”)IrritabilityUse of street drugsPreoccupations or obsessionsAnger control problemsAbuse of prescribed medicationsCompulsions or ritual behaviorsRacing thoughtsImpulsive sexual behaviorsIntrusive or “taboo” thoughtsRapid mood swingsGambling compulsivelyAvoiding people or placesHigh energyFlashbacks of traumatic eventsElevated mood or overly happyFeeling “jumpy” or easily startledTalking too muchSAFETY CONCERNSSuicidal ideasThoughts of harming othersDEPRESSIONALTERNATIVE THOUGHTSPersistent sadnessHearing commands/commentaryCrying spellsSeeing spirits, auras, other energyDespondency or hopelessnessHeightened suspicionIncreased appetiteLoss of interestParanoiaWeight gainGuiltFeelings of being recordedDecreased appetiteLow energyBroadcasting thoughts to othersWeight lossLow motivationSensing the thoughts of othersAnorexiaSuicidal thoughtsPurgingSLEEP PROBLEMSCONCENTRATION PROBLEMSAPPETITE CHANGEBody image problemsI use a sleep aidForgetfulnessDifficulty falling asleepPHYSICAL SYMPTOMSEasily distractedFrequent awakeningPainEasily frustratedEarly morning awakeningSexual problemsJob conflictsNightmaresMuscle tension (jaw, neck, etc.)Schoolwork problemsSleep/wake cycle (timing) offsetHave you experienced a major stress or stresses that has been affecting your mood, or caused it tochange?Describe you mood, or caused it to change?Have you had any physical ailments that havePleasebeen affectingDescribeHas anything been helping you feel better, orPleasemaintainyour mood?Please Describe
THE CENTER FOR ANXIETY AND DEPRESSIONMedical History FormMental-Health Treatment History: Please list past psychiatric treatment providers, both outpatient and inpatient, as well asany substance abuse counseling or treatments.DatesDetailsMajor Medical/Surgical History:(History of seizures, thyroid problems, diabetes, gastric bypass, brain injuries, all others)Please DescribeDate of last physical examPrimary care provider name or clinic nameContact phone numberPATIENT’S birth history:Full-term, uncomplicatedvaginal sYes/NoOther NeonatalComplicationWomen Only:Last MenstrualPeriodNumber of timespregnantCycles ( days, regular/irregular)Number ofLive BirthsCurrent form ofcontraceptionHysterectomy (yes/no, age )Oopharectomy (yes/no, age )Review of Physical Systems: (please check all that apply)ALLERGIESEnvironmental AllergiesHEAD AND NECKYesNoGASTROINTESTINALNoMUSCULOSKELETALPeptic ulcer diseaseTraumatic InjuryHepatitisRheumatoid ArthritisIrritable Bowel SyndromeOsteoarthritisHead trauma with blackoutOther loss of consciousnessYesOther neRespiratory problemsFrequent UTIMultiple SclerosisCardiac problemsSexually transmitted diseaseCVA or StrokeOther head problemsGENITOURINARYKidney problemsSKIN AND BREASTSOther GenitourinaryproblemsNeck problemsEczemaLymph node problemsRaynaudsMouth problemsStevens JohnsonDiabetesTongue problemsPsoriasisThyroid problemsThroat problemsOther skin problemsLupusOther neck or mouth problemBreast nodules/lumpsCancerIMMUNOLOGICYesNo
THE CENTER FOR ANXIETY AND DEPRESSIONMedical History FormSubstance Screening Questions:How much alcohol do you consume:Presently: In the past (if different):If you drink alcohol presently, have you ever tried to cut back on your drinking?Are you annoyed if/when others comment on how much you drink?Do you feel guilty about your drinking behavior?Do you ever drink in the mornings?Have you ever been cited for driving while intoxicated?Do you currently, or Did you ever use 'street' drugs or abuse prescription medicines?YesYesYesYesYesNoNoNoNoNoYes NoPlease DescribeDo you smoke cigarettes? Yes No If yes, how much? Would you like to quit?Do you drink caffeinated drinks? Yes No If yes, how many?Social Screening Questions:With whom do you live?Please describe your work history:Please describe your marital history:How many children do you have?What is your educationalbackground?Have you ever been in the military?Do you practice a religion?Please describe any speech, learningor other developmental delays:Do you have a history of trauma orabuse?Do you have any legal problems?
THE CENTER FOR ANXIETY AND DEPRESSIONMedical History FormFamily History: Please list any blood-relatives you have with a history of mental health problems:DepressionAnxietyBipolar DisorderOCDCompleted SuicideSchizophreniaADD/ADHDAlcoholismDrug Abuse/DependenceDementia(other)Consent for Treatment at The Center For Anxiety and DepressionI give permission for my psychiatrist, Dr. David Dunner, Dr. Christina Demopulos or Dr. Ryan Fugate, to conduct apsychiatric evaluation for the purpose of diagnosis and treatment planning. In addition, it is my right and responsibility toparticipate in the treatment decisions made by my psychiatrist, and this includes providing full and accurate informationregarding my medical conditions, prior treatments, substance use and current symptoms. It may be useful to have personsknowledgeable about my condition to accompany me during my interview and subsequent treatment sessions, and I givepermission for this to occur.I have been provided with a fee schedule, and I understand that I am responsible for payment in full at the time of serviceunless other arrangements have been agreed upon prior to my visit. I have been informed that my psychiatrist does notparticipate in insurance plans or third-party payer systems, including Medicare and Medicaid. I understand that it is myresponsibility to know the provisions of my health plan regarding the possibility of reimbursement if I choose to pursue it.I understand that my psychiatrist may exchange limited information from the health record, from time-to-time, with otherphysicians within The Center for Anxiety and Depression as well as covering physicians from the call coverage group. Thisexchange is only as my psychiatrist deems necessary for urgent purposes or for routine practice decisions. This informationmay include but is not limited to my medical and psychiatric records, drug and alcohol treatment records, informationregarding HIV and AIDS, diagnosis, progress notes, psychiatric evaluations, testing results, therapy notes, sexual assault ordomestic violence notes, sexually transmitted disease information, medication lists and billing information.I am aware that beginning Thursday afternoon and ending Monday morning there is a psychiatrist on-call covering for mypsychiatrist. I am aware that I need to call the Center for Anxiety and Depression (206-230-0330) and determine from thephone message who the on-call psychiatrist is. I am also aware that the on-call psychiatrist is not likely to prescribebenzodiazepines such as Klonopin (clonazepam), Ativan (lorazepam), or Xanax (alprazolam); sleeping medications such asAmbien (zolpidem); narcotics or opioids such as Suboxone (buprenorphine); or stimulants such as Adderall (amphetamine)or Ritalin (methylphenidate). It is my responsibility to arrange prescription renewal for such medications prior to Thursdayfrom my psychiatrist. During Christmas and New Year’s holidays the psychiatry coverage system operates for the entire twoweek period.I am aware that the use of eMail to correspond with my psychiatrist is discouraged as eMail is not secure.I have read the provisions above, and hereby consent to treatment.Patient's full legal namePatient's SignatureDate of BirthToday's Date
THE CENTER FOR ANXIETY AND DEPRESSION Medical History Form Family History: Please list any blood-relatives you have with a history of mental health problems: Consent for Treatment at The Center For Anxiety and Depression I give permission for my psychiatrist, Dr. David Dunner, Dr. Christina Demopulos or Dr. Ryan Fugate, to conduct a
