Patient Intake

Patient Intake
Patient First Name:*
Patient Last Name:*
Date of Birth*

MonthDayYear
Home Phone #
Format: (000) 000-0000.
Email
Cell Phone #
Format: (000) 000-0000.
Address

Street Address Line 2
Highest Level of Education
Birthplace
How many years have you lived in Florida?
Please put "1" year if it's less then 12 months.
Employer
Work Phone #
Please enter a valid phone number.Format: (000) 000-0000.
SingleEngagedLiving TogetherMarriedSeparatedDivorcedWidowedOther
Name of Spouse

First NameLast Name
Spouse’s Employer
Referred by
Your Children
Emergency Contact
Name
Relationship
Emergency Home Phone
Format: (000) 000-0000.
Emergency Work Phone
Format: (000) 000-0000.
Emergency Cell Phone
Format: (000) 000-0000.
Reason for seeking therapy at this time:
YesNo
Please indicate the following information about your past mental health services: Previous Provider, Date(s) of Treatment, & Reason for seeking Services:
Primary Physician
Physician's Phone #
Format: (000) 000-0000.
Past medical history (previous injuries, accidents, surgeries, etc. Please describe and include approximate dates:
Please list any medical tests you have had within the past year:
YesNo
Current Medications (prescription and non-prescription)
What daily activities are you finding difficult or are limited because of your above complaints:
Have you ever had this problem before, and if so when?
Please list any other kind of healthcare professional you are seeing for this/these problem(s):
AbusedCriticizedOverworkedParalyzedDepressedRejectedDespairHelplessHopelessParanoidOverwhelmedMuddledPersecutedGuiltyEasily irritatedAnxiousSadGrievingUnable to grieveApprehensiveAgitatedUneasyDistressFearfulImpatientIntimidatedRestlessPanicIntolerantUncertaintyAggravatedAnnoyedAngryOutragedNervousWorried

Please mark the circle that best describes the level of stress for the below listings.

Rows	None	Minimal	Moderate	Severe
My family stress is:
My relationship stress is:
My work stress is:
My financial stress is:
My health stress is:
Other stress is

How much time do you have for yourself to relax and what do you do to relax, ie. hobbies, meditation, etc ?
YesNo
What kind of exercise and how often?
How many hours a night do you sleep?
YesNo
Please explain more details about your nightly sleep:

Please list areas of pain and mark the circle that best describes the level of discomfort on a scale of 1 to 10.

Level of Discomfort	Description of Discomfort
1	Slight awareness of discomfort.
2-3	Awareness of discomfort.
4-6	Pain is strong but you are still functional.
7-9	Pain is so strong you are unable to function normally.
10	You feel like you need to go to the emergency room.

Please number of areas on your body with pain or discomfort.
Body Part 1
Level of Discomfort

1

2

3

4

5

6

7

8

9

10

1 is Least Pain, 10 is Most Pain
Body Part 2
Level of Discomfort

1

2

3

4

5

6

7

8

9

10

1 is , 10 is
Body Part 3
Level of Discomfort

1

2

3

4

5

6

7

8

9

10

1 is , 10 is
Body Part 4
Level of Discomfort

1

2

3

4

5

6

7

8

9

10

1 is , 10 is
Body Part 5
Level of Discomfort

1

2

3

4

5

6

7

8

9

10

1 is , 10 is
Please shade areas of pain or discomfort on the body diagrams and make comments on the side if necessary:
Comments
eSignature*
Date*

YearMonthDay
Date
Time*

Hour Minutes
Patient
Should be Empty:

Patient Intake

Emergency Contact