ADULT INTAKE INFORMATION
Quality Life
NAME:
DATE:
 /
Month
 /
Day
Year
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Email
example@example.com
Phone Number
Please enter a valid phone number.
OCCUPATION:
LIVING SITUATION:
Level of Work Stress
Please Select
1
2
3
4
5
6
7
8
9
10
Please Select
Level of Personal Stress
Please Select
1
2
3
4
5
6
7
8
9
10
Please Select
Reason for Appointment:
RELIGION/SPIRITUALITY: Do you (the patient) consider yourself spiritual or religious? Do you belong to a spiritual community?
Yes
No
Have you experienced:
increase/decrease in spiritual interest
loss of family member, friend or significant other
change in expectations for your health
change in your relationship w/ God or deity
use prayer in your life
increased fear, anger or bitterness
a feeling that life is meaningless or empty
feeling of lingering sadness
MEDITATION PRACTICE:
STRESS REDUCTION/RELAXATION:
EXERCISE HABITS:
SLEEPING HABITS:
EATING HABITS
CAGEAID - Have you ever. . .
felt you ought to cut down in your drinking or drug use?
had people annoy you by criticizing your drinking or drug use?
felt bad or guilty about your drinking or drug use?
had a drink or used drugs as an eye opener first thing in the morning to steady your nerves or get rid of a hangover or to get the
CURRENT HEALTH CARE PROVIDERS:
Has anyone ever told you that your moods seem to change a great deal?
YES
No
Do you often have days when your mood changes a great deal - days when you shift back and forth from feeling like your usual self to feeling angry or depressed or anxious?
YES
No
If yes, how intense are your mood swings?
How often does this happen in a typical week?
IF YOU HAD 3 WISHES ABOUT ANY CHANGES IN YOURSELF, SCHOOL, WORK, FAMILY, WHAT WOULD THEY BE:
SIGNIFICANT PAST MEDICAL HISTORY:
ARE YOU SEXUALLY ACTIVE?
YES
NO
DO YOU PRACTICE SAFE SEX?
YES
NO
HAVE YOU HAD OR DO YOU HAVE A VENERAL DISEASE?
YES
NO
IF YES PLEASE EXPLAIN:
Birth Control: Diaphragm/Condom Other:
Sexual Orientation:
Please Select
Heterosexual
Homosexual
Bisexual
Please select
Preferred Pronoun:
Please Select
He
She
Please select
STRENGTHS:
athletic
sense of humor
sociable
social support
intelligent
problem solving skills
follow rules
caring
cognitive/intellect
confident
school/work function
family support
communicate well
Other
WEAKNESSES:
problem solving skills
frightens easily
physical health
impatient
cognitive/intellect
work functioning
housing situation
shy
angry
family support
argumentative
social support
impulsive
Other
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Quality Life H & P
Drug Allergies:
WOMEN ONLY:
Pregnant:
Yes
No
Planning Pregnancy?
Yes
No
MEN ONLY:
It is common for men to occasionally experience erection difficulties. Is this something that happens to you?
Never
Rarely
Sometimes
Frequently
MEDICAL HISTORY
Headaches
Lactose Intolerance
Depression
Shortness of Breath
Gallbladder Disease
Gout
Heart Attack
Prostate Disease
Scarlet Fever
Heart Murmur
Bowel Irregularity
Chronic Rashes
Chest Pain
Incontinence
Rheumatic Fever
Dizziness/Fainting
Sexual/Menstrual dysfunction
Mumps
Peripheral Vascular Disease
Venereal Disease
Measles
Allergies/Hay Fever
Frequent Infections
Rubella
Asthma
Hepatitis
Polio
Bronchitis
Anemia
Diptheria
Pneumonia
Arthritis
Tetanus
Ulcer
Osteoporosis
Other
GI Disorder
Nervousness
FAMILY HISTORY
Â
FATHER
MOTHER
FATHER'S
PARENTS
MOTHER'S
PARENTS
SIBLINGS
CHILDREN
HEART DISEASE
HIGH BLOOD PRESSURE
STROKE
CANCER
GLAUCOMA
DIABETES
EPILEPSY/
CONVULSIONS
BLEEDING DISORDER
KIDNEY DISEASE
THYROID DISEASEl
MENTAL ILLNESS
OSTEOPOROSIS
MEDICATION HISTORY
ATYPICAL MOOD STABILIZERS
Â
Currently
Mg/dose
Previously
Any thoughts?
Ariprazole/Abilify
Asenapine/Saphris
Brexpiprazole/Rexulti
Clozapine/Clozaril
Haloperdol/Haldol
Lurasidone/Latuda
Olanzapine/Zyprexa
Paliperidone/Invega
Quetiapine/Seroquel
Risperdone/Risperdal
Ziprasidone/Geodon
ANTI-ANXIETY MEDICATIONS
Â
Currently
Mg/Dose
Previously
Mg/Dose
Alprazolam/Xanax
Buspirone/Buspar
Clonazepam/Klonopin
Diazepam/Valium
Hydroxyzine/Vistaril
ANTIDEPRESSANTS
Â
Currently
Mg/Dose
Previoiusly
Mg/Dose
Amitriptyline/Elavil
Buproprion/Wellbutrin
Citalopram/Celexa
Desipramine/Cymbalta
Escitalopram/Lexapro
Fluoxetine/Prozac
Fluvoxamine/Luvox
Levomilnacipran/Fetzima
Imipramine/Norpramin
Mirtazapine/Remeron
Nortriptyline/Pamelor
Paroxetine/Paxil
Sertraline/Zoloft
Trazodone/Desyrel
Venlafaxine/Effexor
Vilazodone/Viibrid
Vortioxetine/Trintellix
ANTI-EPILEPTIC/MOOD STABILIZERS
Â
CURRENTLY TAKING
MG/DOSE
PREVIOUSLY TOOK
MG/DOSE
Carbamazepine/Tegretol
Gabapentin/Neurotin
Lamotrigine/Lamictal
Levetiracetam/Keppra
Oxcarbazepine/Trileptal
Topiramate/Topomax
Valproate/Depakote
Lithium
Psychiatric Hospitalizations
Click on the plus sign to add more (+)
Please provide details - Name of hospital/Dates/Reason:
Outpatient Services/Therapy
Click on the plus sign to add more (+)
Name of Provider Dates Reason
Neuropsych/psychological Testing
Click on the plus sign to add more (+)
Where? Tests Performed? Outcome/Diagnosis
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MOOD DISORDER QUESTIONNAIRE
Please answer each question to the best of your ability. Check all that apply.
Has there ever been a time when you did not feel like your usual self and . . .
Â
YES
NO
. . . 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 into trouble?
. . . you were so irritable that you shouted at people or started fights or arguments?
. . . you felt much more self-confident that 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?
. . . 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 dd things that were unusual for you or that other people might have thought were excessive, foolish or risky?
. . . 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 at the same time?
3.  Have any of your blood relatives (i.e. children, siblings, parents, grandparents, aunts, uncles) had manic-depressive illness or bipolar disorder?
4.  Has a health professional ever told you that you have manic-depressive illness or bipolar disorder?
How much of a problem did any of these cause you?
No Problem
Minor Problem
Moderate Problem
Serious Problem
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MOOD CHECK
Please choose the statements below that accurately describe you.
PART A: During times when I am not using drugs or alcohol:
I notice that my mood and/or energy levels shift drastically from time to time.
At times I am moody and/or energy level is very low, and at other times very high.
During my "low" phases, I often feel a lack of energy, a need to stay in bed or get extra sleep, and little or no motivation to do the things I need to do.
I often put on weight during these periods.
During my "low" phases I often feel "blue", sad all the time or depressed.
Sometimes during the low phases, I feel helpless or even suicidal.
During the low phases, my ability to function at work or socially is impaired.
Typically the low phases last for a few weeks, but sometimes they last only a few days.
I also experience a period of "normal" mood in between mood swings, during which my mood and energy level feels "right" and my ability to function is not disturbed.
I then notice a marked shift or "switch" in the way I feel.
My energy increases above what is normal for me, and I often get many things done I would not ordinarily be able to do.
Sometimes during those "high" periodsI feel as if I have too much energy or feel "hyper".
During these high periods I may feel irritable, "on edge", or aggressive.
During the high periods I may take on too many activities at once.
During the high periods I may spend money in ways that cause me trouble.
I may be more talkative, outgoing or sexual during these periods.
Sometimes my behavior during the high periods seems strange or annoying to others.
Sometimes I get into difficulty with co-workers or police during these high periods.
Sometimes I increase my alcohol or nonprescription drug use during the high periods.
PART B: The statements in Part A (not just those checked) describe me:
Not at All (0)
A little (2)
Fairly well (4)
Very well (6)
PART C: Please indicate whether any of your (blood) relatives have had any of these concerns:
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GRANDPARENTS
PARENTS
AUNTS/
UNCLES
BROTHERS/
SISTERS
CHILDREN
SUICIDE
ALCOHOL/DRUG PROBLEMS
MENTAL HOSPITAL
DEPRESSION PROBLEMS
MANIC OR BIPOLAR
Has a health professional ever told you that you have manic-depressive illness or bipolar?
YES
NO
Have you ever attempted suicide?
YES
NO
PART D:
How old were you when you were first depressed?
How many episodes of depression have you had?
Please Select
1
2-4
5-6
>10
Have anti-depressants ever caused (check all that apply)?
Excessive Energy
Severe Insomnia
Agitation
Irritability
Racing Thoughts
Talking a Lot
How many antidepressants have you tried, if any?
None
3
1
>3
2
Has an antidepressant you took worked at first, then stopped working?
Yes
No
Do your episodes START gradually or suddenly?
Do your episodes STOP gradually or suddenly?
Did you have an episode after giving birth?
Are your moods much different at different times of the year?
When you are depressed do you sleep differently?
When you are depressed do you eat differently?
When you are depressed what happens to your energy?
In episodes, have you lost contact with reality? (delusions, voices, people thought you were odd)
Yes
No
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LIFE EVENTS CHECKLIST
Listed below are a number of difficult or stressful things that sometimes happen to people. For each event check one or more of the boxes to the right to indicate that (a) it HAPPENDED TO YOU personally, (b) you WITNESSED IT happen to someone else , (c) you LEARNED ABOUT IT happening to someone close to you, (d) you are NOT SURE if it fits, or (e) it DOESN'T APPLY to you.
Be sure you consider your ENTIRE LIFE (growing up as well as adulthood) as you go through the list of events.
Â
Happened to Me
Witnessed It
Learned About It
Not Sure
Doesn't Apply
1. Natural disaster (for example, flood, hurricane, tornado, earthquake)
2. Fire or explosion.
3. Transportation accident (for example car accident, boat accident, train wreck, plane crash).
4. Serious accident at work, home, or during recreational activity.
5. Exposure to toxic substance (for example, dangerous chemicals, radiation).
6. Physical assault (for example being attacked, hit, slapped, kicked, beaten up).
7. Assault with a weapon (for example being shot, stabbed, threatened with a knife, gun, bomb).
8. Sexual assault (rape, attempted rape, made to perform any type of sexual act through force or threat of harm).
9. Other unwanted or uncomfortable sexual experience.
10. Combat or exposure to a war-zone (in the military or as a civilian).
11. Captivity (for example being kidnapped, abducted, held hostage, prisoner of war).
12. Life threatening illness or injury.
13. Severe human suffering.
14. Sudden violent death (for example homicide or suicide).
15. Sudden unexpected death of someone close to you.
16. Serious injury, harm, or death you caused to someone else.
17. Any other very stressful event or experience.
WENDER UTAH RATING SCALE
Please choose one option for each item below:
Â
Not at
All
Mildly
Moderately
Quite a
Bit
Very
Much
AS A CHILD I WAS OR HAD:
1. Active, restless, always on the go.
2. Afraid of things.
3. Concentration problems, easily distracted.
4. Anxious, worrying.
5. Nervous, fidgety.
6. Inattentive, day dreaming
7. Hot, short tempered, low boiling point.
8. Shy, sensitive.
9. Temper, outbursts, tantrums.
10. Trouble with stick-to-it-iveness, not following through, failing
to finish things started.
11. Stubborn, strong-willed.
12. Sad or blue, depressed unhappy.
13. Unconscious, dare-devilish involved in pranks.
14. Not getting a kick out of things, dissatisfiedl with life.
15. Disobedient with parents, rebellous, sassy.
16. Low opinion of myself.
17. Irritable.
18. Outgoing, friendly, enjoy company of people.
19. Sloppy, disorganized.
20. Moody, have ups and downs.
21. Feel angry.
22. Have friends, popular.
23. Well organized, tidy, neat.
24. Acting without thinking, impulsive.
25. Tend to be immature.
26. Feel guilty, regretful.
27. Lose control of myself.
28. Tend to be or act irrational.
29. Unpopular with other children, didn't keep friends for long, didn't get along
with others.
30. Poorly coordinated, did not participate in sports.
31. Afraid of losing control of self.
32. Well coordinated, picked first in games.
33. T
omboyish (for women only)
34. Ran away from home.
35. Get in fights.
36. Teased other children.
37. Leader, bossy.
38. Difficulty getting awake.
39. Follower, lead around too much.
40. Trouble seeing things from someone else's point.
41. Trouble with authorities, trouble with school, visits to principal's office.
42. Trouble with police, booked, convicted.
MEDICAL PROBLEMS AS A CHILD
43. Headaches
44. Stomach aches
45. Constipation
46. Diarrhea
47. Food Allergies
48. Other allergies
49. Bedwetting
AS A CHILD IN SCHOOL:
50. Overall good student, fast learner.
51. Overall poor student, slow learner.
52. Slow reader.
53. Slow in
learning
to read.
54. Trouble reversing letters.
55. Problems with spelling.
56. Trouble with mathematics or numbers.
57. Bad handwriting.
58. Though I could read pretty well, I never really enjoyed it.
59. Did not achieve up to potential.
60. Repeated grades.
61. Suspended or expelled.
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