Patient Information and History
Please fill out the form completely and submit before your first appointment.
Name:
Address
Phone (preferred):
Date:
/
Month
/
Day
Year
Date
Referred By:
Personal Physician
Date of Birth:
/
Month
/
Day
Year
Date
Last four digits of social security number
Reason for Consultation:
History of Current Problem:
Previous Psychological / Psychiatric Treatment:
Clinicians Name
Treatment Type
Treatment Dates
Response to Treatment
Psychopharmacologic (medication) History:
Medication
Dates (from - to)
Responde to Medication
Medication
Dates (from - to)
Response to Medication
Medication
Date (from - to)
Response to Medication
Current Medications - indicate dosage
Childhood History:
Please comment on the presence of the following during childhood
Hyperactivity Learning Difficulties Conduct Problems Night Terrors Unrealistic Fears Unhappy Childhood Bed Wetting Trauma/Abuse Unusual Medical IlInesses
Family Psychiatric History:
Has any member of your family ever had a neurological, psychiatric, or psychological problem? Include substance abuse and please note if relative is on your mother's side or father's side.
Family Member
Problem
Treatment for Problem
Family Member
Problem
Treatment for Problem
Family Member
Problem
Treatment for Problem
Medical History:
Nature of Illness or Health Problem
Age
Nature of Illness or Health Problem
Age
Surgical History:
Operation
Age
Complications
Operation
Age
Complications
Accidents:
Please list significant accidents, especially those that involve head trauma.
Nature of accident
Age
Complications
Have you been the victim of a traumatic or abusive life experience? (emotional, physical or sexual)
Substance Abuse History - please list all substances that you have used
General History:
Birthplace
Educational History: (Highest level reached)
Vocation
Marital Status: (If married, how many years)
Children: (if any list ages)
Submit
Should be Empty: