Adult intake form_layout

Psychiatric Evaluation Intake Form

1. Patient Contact Information
Patient Name ________________________ Address ____________________________________________ Best contact phone number ____________________ Email address ________________________________ Emergency contact ________________ Relationship _______________ Phone No ____________________ Primary Care Physician _________________________Tel ____________________Fax__________________________ Pharmacy __________________________________ Phone No _____________________________________________ 2. Date of Birth
M O D A Y Y E A R
Years Old
4. Race/Ethnicity (Check one or more):
5. Current marital status (Check one):
6. If you are married or cohabitating with partner, how long has this been?
7. Total number of marriages? _________ How many children do you have? _________
8. Spouse’s/Partner’s Name_________________________________________________________

9. Who else lives with you? ________________________________________________________
10. How many years of formal education have you completed?
11. Highest degree obtained: (Check only one)
12. What best describes your current employment status? (Check one from each category A, B and C)
A. Employment Status
B. Student Status
C. Volunteer Status
14. What is your current occupation? __________
____________________________________________

15. Current Residence
16. What is your spouse’s occupation? ________________________________________________
Are you currently seeing a therapist? (Name/contact #)__________________________________
Have you ever seen a psychiatrist/psychotherapist before? If yes, please list:_______________
Previous history: Have you ever been treated for any of the following (check all that apply):
_____Bipolar (Manic/Depressive) Disorder _____PTSD (Post Traumatic Stress Discorder) Please list in chronological order all prior psychiatric hospitalizations (if any) below: None
Approximate Date
Length of Stay
Name of Hospital
Reason for Admission
Have you ever attempted to harm/kill yourself? If so, please list the occurrences below: Never
Approximate date of attempt
How did you attempt (method)?
Please List all current medications below (include birth control pills, over the counter medication
and herbal remedies – i.e. decongestants, St. John’s Wort, etc.)
Dosage(Mg) How many
On this for
Side effects
Prescribing
Medication
times a day?
physician
Please review the following list of medications.
If you have taken any of these medications in the
last 48 months, please complete the appropriate boxes
How often
 did you did you
take it? take?
Selective Serotonin Reuptake Inhibitors (SSRIs)
Serotonin - Norepinephrine Reuptake Inhibitors ( SNRIs)
Other Antidepressants
Tricyclic Antidepressants
Other Psychotropics (Have you taken any of these?)
Please circle those you have taken.
Family History: Has anyone in your family ever been treated for any of the following (please check all that
apply and when appropriate indicate paternal or maternal) Father Mother Brother Sister Aunt Uncle Children Grandparent __________________________________________________________________________________________ __________________________________________________________________________________________Anxiety __________________________________________________________________________________________Bi-polar/Manic Depression __________________________________________________________________________________________CHI/TBI - Brain Injury __________________________________________________________________________________________Depression__________________________________________________________________________________________ Drug Problems__________________________________________________________________________________________Panic Attacks __________________________________________________________________________________________Post Traumatic __________________________________________________________________________________________Psychiatric Facility Stay __________________________________________________________________________________________Schizophrenia __________________________________________________________________________________________Suicide Ideation __________________________________________________________________________________________ Medical History:
(please check all that apply to you) Other (print below)
__________________
Regarding alcohol, when was your last drink?______________________________________________
In the past 30 days, about how many of those days have you had at least one alcoholic drink? ________ What is the maximum number of drinks you have had in one day in the past month? ________ drinks DUI ________ DWI ________ Public Intoxication ________ Seizures ________ DT’s ________
Please check the appropriate boxes that apply to you for the following substances:
_________________________________________________________________________________________________ _________________________________________________________________________________________________Anabolic Steroids _________________________________________________________________________________________________Benzodiazepines(Xanax, Valium,Ativan Restoril,Librium) _________________________________________________________________________________________________Caffeine (coffee,tea, colas, iced tea) _________________________________________________________________________________________________Cigarettes,cigars, ortobacco _________________________________________________________________________________________________Cocaine _________________________________________________________________________________________________Diet Pills _________________________________________________________________________________________________Diuretics _________________________________________________________________________________________________Ecstasy _________________________________________________________________________________________________GHB _________________________________________________________________________________________________Hallucinogens (LSD,mushrooms, Mescaline) _________________________________________________________________________________________________Heroin _________________________________________________________________________________________________Inhalants _________________________________________________________________________________________________IV Drug use _________________________________________________________________________________________________Laxatives _________________________________________________________________________________________________Marijuana _________________________________________________________________________________________________Pain Pills _________________________________________________________________________________________________PCP orAngel Dust _________________________________________________________________________________________________Sleeping Pills _________________________________________________________________________________________________Tranquilizers _________________________________________________________________________________________________Other: _________________________________________________________________________________________________ List all prior surgeries and hospitalizations for medical illness:
_________________________________________________________________________________________________ _________________________________________________________________________________________________ Are you allergic to any medication or food? If so, please list below:
_________________________________________________________________________________________________ Last menstrual period (if applicable) ____________________ Contraceptive method: ____________________

Source: http://mentalhealthmichigan.com/wp-content/uploads/2012/02/adult-intake-form.pdf