Psychiatry New Patient Form

Please read the following two documents before proceeding with the questionnaire.

Psychiatry

New Patient Packet : Psychiatry 5th Floor

Before you begin please open and read the two documents above. Once you are finished reading the Controlled Substance Agreement and Consent for Evaluation and / or Treatment form please sign and date below then proceed with the questions.

Printed Patient Name *

First

Last

These agreements are enter into on *

Date of Birth *

Patient Signature *

1. Demographic Information

Name that appears on your I.D. *

First

Last

Preferred Name

Former/ Maiden Name

Social Security Number *

Date of Birth *

Age *

Phone Number *

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Insurance Carrier *

Member ID *

What pharmacy do you use? *

Pharmacy's address?

Address Line 1

Address Line 2

City

State

Zip Code

Ethnicity

Race

Emergency Contact Name *

Emergency Contact Relation

Emergency Contact Phone Number *

Marital Status *

Sexual Orientation

Were you referred by a physician? *

If yes, what is the name of Referring Physician

Referring Physician Phone Number

Name of Primary Care Physician / Phone Number

Name of Therapist / Counselor and Phone Number

Please write the reason(s) you are seeing a psychiatrist (Must be completed): *

2.

Do you have problems with sleep *

Please list all medications you are currently taking with dosages: (include vitamins/supplements)

Name of Medication: *

Dose (How much do you take): *

Frequency (When do you take): *

3. Medical History

Height (Feet and Inches) *

Weight (lbs) *

Handedness *

If yes to head injury, any loss of consciousness?

Longer than five minutes?

Are you currently on hormone replacement therapy? *

Have you ever been on oral steroids for more than 3 months? *

Have you ever been on an anticonvulsant? *

If yes, which?

Please list any additional medical conditions

Do you have any allergies or known drug allergies? *

If yes, please list and include your reaction(s

Please list any hospitalizations and/or surgeries:

FOR Menstruating's Females (Skip if Male)

Date of your last period:

Are you currently pregnant or trying to become pregnant?

Are you currently breastfeeding?

Are you currently on birth control?

4. Prior Psychiatric History

If so, please list who and when: (Include Names and Dates) *

*Provide any additional Names or Information

Have you ever been hospitalized for a psychiatric disorder? *

If so, please list where and when: (Facility / Dates) *

*Provide any additional information

5. Prior Psychiatric History (Continued)

Have you ever tried to hurt yourself or others? *

If so, please list who and when: *

6. Family Psychiatric History

Please describe any family history of psychiatric illness, mental health treatment, alcoholism, or drug use: (parents, siblings, extended family members) *

Has anyone: *

Been psychiatrically hospitalized
Received psychiatric treatment
Neither

If yes, who?

Has anyone attempted to commit suicide? *

If yes, who?

Has anyone committed suicide? *

If yes, who?

7. Family Medical History (Diabetes, Stroke, Heart Disease, Cancer, etc.):

Please list any medical conditions of the following family members:

Layout

Father:

Alive?

If no, cause of Father's death and/or illness:

Layout (copy)

Mother:

Mother Alive?

If no, cause of Mother's death and/or illness:

8. Substance Use/Abuse History

Alcohol

Have you ever had any alcohol? *

Date you last drank (if not applicable, please type N/A): *

Age when you first had a drink (if not applicable, please type N/A):? *

Drink of choice? *

Beer
Wine
Liquor
NONE

How often do you drink? (if not applicable, please type N/A) *

Illicit / Street drug

Have you ever used illicit / street drugs? *

How often do you use drugs? (if not applicable, please type N/A) *

If yes, please list: *

Date you last used drugs: (if not applicable, please type N/A) *

Age you first used drugs: (if not applicable, please type N/A) *

What did you use? (if not applicable, please type N/A) *

Tobacco

Have you ever smoked tobacco? *

How often do you smoke? (if not applicable, please type N/A) *

Date you quit : (if not applicable, please type N/A) *

Are you currently a smoker? *

How many packs per day? (if not applicable, please type N/A) *

Age you first smoked tobacco: (if not applicable, please type N/A) *

Number of attempts at quitting: (if not applicable, please type N/A) *

Have you sought substance/alcohol abuse treatment in the past? *

Are you currently involved in substance/alcohol abuse treatment? *

Do you currently have or had in the past any legal issues related to substance or alcohol? *

Please list all treatment programs you have been involved in or are currently involved in: (Please include dates, length of treatment, any AA/NA/SOS meetings, frequency per week, sponsor) *

9. Social History

Please list whom you live with: *

Do you have access to housing? *

Do you have access to food? *

Do you have a good support system? (Including family and/or friends) *

If yes, please list who: *

Do you have any children? *

If yes, how many? *

10. Legal

Legal

Do you have any pending legal issues? *

If yes, what are they? (copy) *

Do you have any pending court appearances? *

If yes, please list when and what for: *

11. Work

Work

Are you currently employed? *

Current title/position: *

Employer: *

Are you currently on disability? *

If yes, date you became disabled *

Who put you on disability? *

12. Interests / Leisure

Please list any hobbies/activities you enjoy: *

13. Development

14. More about you!

Is there anything else you would like to add about yourself that has not been covered? *

Mood Disorder Questionnaire (MDQ)

Instructions: Please answer each question as best as you can.

1. Has there ever been a period of time when you were not your usual self and…

…you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got in trouble? *

…you were so irritable that you shouted at people or started fights or arguments? *

…you felt much more self-confident than usual? *

…you got much less sleep than usual and found you didn’t really miss it? *

…you were much more talkative or spoke much faster than usual? *

...your thoughts raced through your head or you couldn’t slow your mind down? *

…you were so easily distracted by things around you that you had trouble concentrating or staying on track? *

…you had much more energy than usual?

…you were much more active or did many more things than usual? *

…you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night? *

…you were much more interested in sex than usual? *

…you did things that were unusual for you or that other people might have thought were excessive, risky, or foolish? *

…spending money got you or your family in trouble? *

2. If you checked YES to more than one of the above, have several of these ever happened during the same period of time? *

3. How much of a problem did any of these cause you – like being unable to work; having family, money or legal troubles; getting into arguments or fights? Please circle one response only *

No problem
Minor problem
Moderate problem
Serious problem

4. Have any of your blood relatives (i.e., children, siblings, parents, grandparents, aunts, uncles) had manic-depressive illness or bipolar disorder? *

5. Has a health professional ever told you that you have manic-depressive illness or bipolar disorder? *

Please check any of the following medications that you have previously tried. If possible, please add at what doses you tried the medication(s) and any side effects or adverse effects at the bottom. If none have been tried please check (NONE) Thank you.

If possible, please add at what doses you tried the medication(s) and any side effects or adverse effects. *

SIGNATURE REQUIRED

I acknowledge that the above information is correct and co-relates with my psychiatric history to the best of my knowledge. *

Name *

First

Last

Date Completed *

Date of Birth *

716-250-2000

Please read the following two documents before proceeding with the questionnaire.

Psychiatry

Before you begin please open and read the two documents above. Once you are finished reading the Controlled Substance Agreement and Consent for Evaluation and / or Treatment form please sign and date below then proceed with the questions.

1. Demographic Information

2.

3. Medical History

FOR Menstruating's Females (Skip if Male)

4. Prior Psychiatric History

5. Prior Psychiatric History (Continued)

6. Family Psychiatric History

7. Family Medical History (Diabetes, Stroke, Heart Disease, Cancer, etc.):

Please list any medical conditions of the following family members:

8. Substance Use/Abuse History

9. Social History

10. Legal

11. Work

12. Interests / Leisure

13. Development

14. More about you!

Mood Disorder Questionnaire (MDQ)

1. Has there ever been a period of time when you were not your usual self and…

Please check any of the following medications that you have previously tried. If possible, please add at what doses you tried the medication(s) and any side effects or adverse effects at the bottom. If none have been tried please check (NONE) Thank you.

SIGNATURE REQUIRED